Two more state-level experiments to support primary care have failed. Before I go over the findings, let me first say that I appreciate that some states are willing to think big and take risks by trying new approaches. Change is hard. One of the real strengths of America has been its history of having 50 independent laboratories that can try different approaches to societal problems. The states can compare notes on what works or not, and adjust their plans accordingly. It makes sense that relatively small states are a great laboratory for experimentation in healthcare delivery.
OK, now for the bad news. Rhode Island was yet another entity that went all in on a version of the patient-centered medical home (PCMH). It was state-wide, multipayer, and covered one-third of the state population. They analyzed claims data from 2009-14. There was increase in outpatient and professional costs and small decreases in ED and inpatient costs. There was no impact on total costs.
Hawaii introduced a capitation-based primary care payment system that included about 77,000 patients and 107 physicians initially and grew to 299,000 patients total. There were tiny changes in some quality scores. There were 15 utilization and spending measures, of which 11 showed no change. Primary care visits actually decreased. There was no difference in the total cost of care.
The ideal family medicine experiment has yet to occur. The observational literature – the Barbara Starfield stuff — is that places with more family physicians enjoy better health outcomes at a lower total cost. Therefore, the proper experiment would be to take a low family physician supply part of the country and load it up with family physicians. Give the area a few years for the new physicians to build up their presence, innovate, and change the local medical culture. Then measure all the relevant outcomes a few years after that.
A wonderful editorial in JAMA, in response to another editorial about failed primary care payment experiments, pointed out that there has never been an experiment that supported full spectrum family physicians. The Robert Graham Center has published studies showing that places where the family physicians provide the most comprehensive care have the lowest total costs. Examples of comprehensiveness include caring for hospitalized patients, doing procedures, delivering babies, covering the ER, and providing pain management services, for example.
The literature is now crystal clear that team-based care does not deliver on the promise of family physicians: better health outcomes at a lower cost. It’s time to put this notion to rest and stop future watered-down attempts at growing primary care that have mostly failed. The key to better health outcomes at a lower cost is supporting comprehensive family physicians, not teams. It’s time for major funders to step up.
The current fee for service and capitation rates are so low that they limit primary care to acute care for “sick care ” and triage to specialists who live by more tests and procedures.
The key would be a payment mechanism that allows family physicians to spend enough time with patients to actually
do their full-spectrum, high-value job.
Concierge medicine has shown decreases in ED visits, hospitalizations, and procedures in their patients compared to matched medicare patients in standard care practices.
Patient outcomes and satisfaction were better and the overall costs were lower.
DPC practices working with self-insured employers have also shown similar results.
The next big steps involve integrating Behavioral Health with primary care and greatly increasing our investment in public health to realistically address the social determinants of health.
We know we could have better outcomes at lower costs with better patient and provider experiences, but we lack the will to challenge the many people and organizations that are profiting from the current arrangement.