By Richard Roberts, MD, JD, FAAFP, FCLM

Primary care is at risk of "imminent collapse," according to American College of Physicians in 2006. This article will describe the reasons behind that conclusion, the current state of primary care in the United States, and a strategy for revitalizing primary care: the Patient Centered Medical Home (PCMH).

America Depends on Primary Care

The mode, or most common place, of medical care in America is to be seen by a family doctor who practices in a two- to three-physician practice. While primary care physicians comprise only about one out of four US doctors, they provide more than one out of two doctor visits. When patients have a primary care physician, as opposed to a specialist, as their personal physician, their cost of care is about one-third less and their mortality risk is nearly 20 percent lower.

Using Medicare's 24 quality measures (blood pressure control, glycohemoglobin levels, etc.) to compare states reveals similar benefits attributable to primary care. When the number of primary care physicians in a state is increased by one doctor per 10,000 population, that state's quality ranking goes up 10 states, costs go down $684 per Medicare beneficiary per year, and the death rate goes down five percent. Conversely, when the number of specialists in that state is increased by one doctor per 10,000 population, that state's quality ranking goes down nine states, costs go up $526 per Medicare beneficiary per year, and the death rate goes up two percent.

Overall, according to the 2000 report of the World Health Organization, the US health system's performance is ranked 37th in the world. The key differences between the US and other countries are the better performing health care systems assure universal coverage (i.e., everyone has financial access to health care) and those systems are built on primary care, with 90 percent or more of all health care encounters occurring in the primary care setting.

Primary Care's Challenges

From its zenith during the heyday of managed care in the mid-1990s, medical student interest in primary care has waned. The number of US medical students choosing family medicine residencies peaked at just more than 3,000 in 1995 and dropped to nearly 1,400 by 2007. The 2008 residency match for family medicine showed a slight increase.

Things are much worse for general internal medicine. While the number of students choosing internal medicine residencies has continued to gradually increase to just more than 7,000, about 80 percent of medicine residency graduates go on to sub-specialty fellowships. Of the remaining 20 percent, only 20 percent of those become general internists, with the other 80 percent pursuing careers as hospitalists or later becoming sub-specialists. In other words, just four percent of internists are choosing careers in general medicine. Thus, the number of US general internists is projected to decrease from 92,000 in 2000 to 62,000 in 2010 - and 32,000 by 2020. The impact of this shrinking work force on the care of a rapidly aging population is expected to be dramatic and adverse. Hence, the "imminent collapse" predicted for primary care.

The reasons for these work force changes are numerous and vary from one region or person to another. Rising expectations are one indication of the stresses in primary care. Half or more of visits to primary care doctors are now to manage chronic conditions. The primary care clinician with an average-sized practice would need to spend 10.6 hours each day on chronic conditions and 7.4 hours per day on preventive services to meet current guidelines, leaving very few hours to address the reason(s) that the patient wanted to be seen! The growing burden of formulary hassles, health plan aggravations, and regulatory requirements have taken more time away from direct patient care, which is what primary care doctors love and are trained to do. The end result is more work that is less satisfying and for less pay, as mushrooming practice overhead bumps up against flat or slowly increasing payment levels.

Against this backdrop of increasingly complex care and shrinking primary care work force is the declining availability of those primary care doctors who continue to provide patient care. Overwhelmed with the growing stresses of practice, primary care physicians increasingly seek more part-time positions, ambulatory-only practices, and more confined hours, further reducing primary care access.

Building the Patient Centered Medical Home

Recognizing these discouraging trends and mindful of the essential role played by primary care in the best performing health systems, primary care leaders have endeavored to revitalize primary care through the promotion of the Patient Centered Medical Home (PCMH). The Medical Home was first proposed in 1967 for children with complex health problems who needed a place where care could be integrated and coordinated. In 2004, the Future of Family Medicine project took this concept further and advocated for a PCMH for all Americans.

The PCMH attempts to pull together what have emerged as best practices to improve the access to, safety of, and quality resulting from a primary care practice. While a few current practices or individual doctors may be able to demonstrate some of these best practices, the PCMH represents a fundamental and systematic redesign of the practice for the vast majority of primary care practices.

The specific elements of the PCMH are likely to continue to evolve as more evidence is gathered on its relative value. Some of the elements of the PCMH advocated today include advanced or open access scheduling, online appointments, an electronic health record (EHR), group visits, electronic visits, web-based information for patients, chronic disease management programs, a high functioning multidisciplinary team, clinical practice guideline software embedded into the EHR, outcomes monitoring and reporting, and a payment strategy that blends a care management fee (or capitation payment) with fee-for-service reimbursement and bonus payments for quality performance. Also essential for the successful primary care practice of tomorrow will be the ability to provide robust and integrated behavioral and mental health services.

Much Ado About Nothing?

While the current evidence suggests the PCMH can improve outcomes and satisfac­tion, more study is needed. TransforMED, a subsidiary of the American Academy of Family Physicians, is due to report in 2009 on the findings from 36 demonstration practice sites that have attempted to implement some or all of the elements of the PCMH.

There are some potential pitfalls to the PCMH. While patients are interested in the improved access and services represented by the PCMH, when they are asked about the term "Patient Centered Medical Home," they become confused and wonder whether reference is being made to a nursing home. While the various elements of the PCMH have some evidence to suggest their benefit, it is unclear how much the care and satisfaction of patients will improve by adopting all the elements.

Another concern is the potential for care fragmentation within the primary care team. An example of this is the United Kingdom, where the Quality Outcomes Framework initiative prompted general practices to target chronic conditions like asthma or diabetes by hiring an asthma nurse or diabetes nurse. Now, British GPs are expressing concern about their ability to maintain competence in asthma or diabetes having delegated major segments of care.

Final Thoughts

The PCMH is a useful concept for bringing together the primary care disciplines around a common theme and explaining to policy makers and payers how primary care intends to do better. Ultimately, the PCMH repre­sents a set of tools or strategies that can help primary care accomplish certain processes and tasks. Most important, however, is the recognition that the real value of the primary care practice resides in the continuity rela­tionship with and comprehensive services provided by the primary care physician. Without being Patient Centered and without a trusted patient-doctor relationship, the col­lection of strategies known as the PCMH will fall short and will be seen as only another medical house, and not a valued home.

Richard Roberts, MD, JD, FAAFP, FCLM is a Professor of Family Medicine at University of Wisconsin School of Medicine and Public Health. He is a Past President of the American Academy of Family Physicians and is a President-elect of the World Organization of Family Doctors (WONCA).

REFERENCES:

Rosenthal TG. The Medical Home: growing evidence to support a new approach to primary care. JABFM 2008; 21:427-440.

Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health.