21st-century primary care: new physician roles need new payment models

Quality and team care response to the pandemic stresses in high performing primary care practices: A qualitative study

OBJECTIVE

To learn how high performing primary care practices organized care for patients with diabetes during the initial months of the COVID-19 pandemic.

PARTICIPANTS AND METHODS

Semi-structured interviews were conducted between August 10 and December 10, 2020 with 16 leaders from 11 practices that had top quartile performance measures for diabetes outcomes pre-COVID. Each clinic had completed a similar interview and a survey about the existence of care management systems associated with quality outcomes before the pandemic. Transcript analysis utilized a theoretical thematic analysis at the semantic level.

RESULTS

The pandemic disrupted the primary care practices' operations and processes considered important for quality prior to the pandemic, particularly clinic reliance on proactive patient care. Safety concerns resulted from the shift to virtual visits, which produced documentation gaps and led practices to reorder their use of proactive patient care processes. Informal interactions with patients also declined. These practices' challenges were mitigated by technical, informational and operational help from the larger organizations of which they were a part. Care management processes had to accommodate both in-person and virtual visits.

CONCLUSION

These high performing practices demonstrated an ability to adapt their use of proactive patient care processes in pursuing quality outcomes for patients with diabetes during the pandemic. Continued clinic transformation and improvements in quality within primary care depend on the ability to restructure the responsibilities of care team members and their interactions with patients.

Multiprofessional Primary Care Units: What Affects the Clinical Performance of Italian General Practitioners?

Multiprofessional primary care models promise to deliver better care and reduce waste. This study evaluates the impact of such a model, the primary care unit (PCU), on three outcomes. A multilevel analysis within a "pre- and post-PCU" study design and a cross-sectional analysis were conducted on 215 PCUs located in the Emilia-Romagna region in Italy. Seven dimensions captured a set of processes and services characterizing a well-functioning PCU, or its degree of vitality. The impact of each dimension on outcomes was evaluated. The analyses show that certain dimensions of PCU vitality (i.e., the possibility for general practitioners to meet and share patients) can lead to better outcomes. However, dimensions related to the interaction and the joint works of general practitioners with other professionals tend not to have a significant or positive impact. This suggests that more effort needs to be invested to realize all the potential benefits of the PCU's multiprofessional approach to care.

Connected health: a review of technologies and strategies to improve patient care with telemedicine and telehealth

With the advent of national health reform, millions more Americans are gaining access to a health care system that is struggling to provide high-quality care at reduced costs. The increasing adoption of electronic technologies is widely recognized as a key strategy for making health care more cost-effective. This article examines the concept of connected health as an overarching structure for telemedicine and telehealth, and it provides examples of its value to professionals as well as patients. Policy makers, academe, patient advocacy groups, and private-sector organizations need to create partnerships to rapidly test, evaluate, deploy, and pay for new care models that use telemedicine.

Current yardsticks may be inadequate for measuring quality improvements from the medical home

Health reform legislation grants authority for patient-centered medical home pilot projects to test changes in the way primary care is provided. There is concern that using a measurement tool to qualify medical homes that is solely based on the presence or absence of "system elements" may miss the point conceptually and lead physicians astray in attempts to transform their entire practices. To find out whether and how practice characteristics explain health care quality, we examined risk-adjusted composite measures of quality for common chronic and acute care conditions and preventive care from 202 general internists working primarily in small primary care office settings. We found that current conceptions and measures of what constitutes "successful" practice systems and care are incomplete, and have limited associations with measures of health care quality. Future research should explore more fully the issues around physician competence, including competence in systems and quality improvement; the interactive nature of clinical practice; and other important system elements not captured by current tools.

An assessment of patient-based and practice infrastructure-based measures of the patient-centered medical home: do we need to ask the patient?

OBJECTIVE

To examine the importance of patient-based measures and practice infrastructure measures of the patient-centered medical home (PCMH).

DATA SOURCES

A total of 3,671 patient surveys of 202 physicians completing the American Board of Internal Medicine (ABIM) 2006 Comprehensive Care Practice Improvement Module and 14,457 patient chart reviews from 592 physicians completing ABIM's 2007 Diabetes and Hypertension Practice Improvement Module.

METHODOLOGY

We estimated the association of patient-centered care and practice infrastructure measures with patient rating of physician quality. We then estimated the association of practice infrastructure and patient rating of care quality with blood pressure (BP) control.

RESULTS

Patient-centered care measures dominated practice infrastructure as predictors of patient rating of physician quality. Having all patient-centered care measures in place versus none was associated with an absolute 75.2 percent increase in the likelihood of receiving a top rating. Both patient rating of care quality and practice infrastructure predicted BP control. Receiving a rating of excellent on care quality from all patients was associated with an absolute 4.2 percent improvement in BP control. For reaching the maximum practice-infrastructure score, this figure was 4.5 percent.

CONCLUSION

Assessment of physician practices for PCMH qualification should consider both patient based patient-centered care measures and practice infrastructure measures.

Payment contracts in a preventive health care system: a perspective from operations management

We consider a health care system consisting of two noncooperative parties: a health purchaser (payer) and a health provider, where the interaction between the two parties is governed by a payment contract. We determine the contracts that coordinate the health purchaser-health provider relationship; i.e. the contracts that maximize the population's welfare while allowing each entity to optimize its own objective function. We show that under certain conditions (1) when the number of customers for a preventive medical intervention is verifiable, there exists a gate-keeping contract and a set of concave piecewise linear contracts that coordinate the system, and (2) when the number of customers is not verifiable, there exists a contract of bounded linear form and a set of incentive-feasible concave piecewise linear contracts that coordinate the system.

A house is not a home: keeping patients at the center of practice redesign

The "patient-centered medical home" has been promoted as an enhanced model of primary care. Based on a literature review and interviews with practicing physicians, we find that medical home advocates and physicians have somewhat different, although not necessarily inconsistent, expectations of what the medical home should accomplish-from greater responsiveness to the needs of all patients to increased focus on care management for patients with chronic conditions. As the medical home concept is further developed, it will be important to not overemphasize redesign of practices at the expense of patient-centered care, which is the hallmark of excellent primary care.

[The Bellagio Model: an evidence-informed, international framework for population-oriented primary care. First experiences]

The Bellagio Model for Population-oriented Primary Care is an evidence-informed framework to assess accessible care for sick, vulnerable, and healthy people. The model was developed in spring 2008 by a multidisciplinary group of 24 experts from nine countries. The purpose of their gathering was to determine success factors for effective 21st century primary care based on state-of-the-art research findings, models, and empirical experience, and to assist with its implementation in practice, management, and health policy. Against the backdrop of "partialization", fragmentation in open health care systems, and the growing numbers of chronically ill or fragile people or those in need of any other kind of care, today's health care systems do not provide the much needed anchor point for continuing coordination and assistance prior, during and following an episode of illness. The Bellagio Model consists of ten key elements, which can make a substantial contribution to identify and overcome current gaps in primary care by using a synergetic approach. These elements are Shared Leadership, Public Trust, Horizontal and Vertical Integration, Networking of Professionals, Standardized Measurement, Research and Development, Payment Mix, Infrastructure, Programmes for Practice Improvement, and Population-oriented Management. All of these elements, which have been identified as being equally necessary, are also alike in that they involve all those responsible for health care: providers, managers, and policymakers.

Gaps in addressing problem drinking: overcoming primary care and alcohol treatment deficiencies

Despite the high prevalence of problem drinking among Americans, primary care physicians often fail to address this major health threat. In addition, once alcohol use disorders are identified, patients often fail to receive coordinated medical and substance abuse treatment. This article reviews four types of barriers as well as potential facilitators to improving the prevention and management of problem drinking. First, primary care physicians are poorly trained about the clinical relevance of addressing alcohol problems in their daily patient care. Second, primary care physicians are concerned about the stigma and health insurance problems encountered by patients diagnosed with alcohol use disorders. Third, primary care practices have limited organizational and financial support to identify and address alcohol problems. Fourth, primary care and alcohol treatment settings communicate and collaborate poorly in delivering patient care. Opportunities to overcome these challenges are discussed and must be initiated to reduce the myriad of adverse outcomes resulting from problem drinking.

Desafios da atenção básica em saúde: a experiência de Vila Mariana, São Paulo, Brasil

Este artigo apresenta resultados de estudo de caso visando identificar desafios na oferta de atenção básica à saúde em um distrito de saúde da cidade de São Paulo, Brasil, considerando integralidade como dispositivo organizador do trabalho neste nível de atenção. Foram estudadas as cinco unidades que compõem a rede de atenção básica à saúde no distrito considerado. Os dados foram coletados mediante observação dos fluxos e rotinas de atendimento, realização de entrevistas com gerentes e profissionais de diferentes formações e ainda realização de grupos focais com equipes de saúde da família. A análise mostra um descompasso entre as características da clientela e suas necessidades presumidas e as ofertas dos serviços, e heterogeneidade nas percepções dos profissionais sobre seu trabalho. Falta de profissionais, de tempo, e dificuldades para encaminhamentos foram os principais problemas apontados pelos entrevistados.

What can data tell us about the quality and relevance of current pediatric residency education?

The Residency Review and Redesign (R(3)P) Project relied on both qualitative and quantitative data in developing its recommendations regarding residency education. This article reviews quantitative data in the published literature of import to the R(3)P Project as well as findings by Freed and colleagues published in this supplement to Pediatrics. Primary questions of interest to the R(3)P Project included: What factors drive decision-making regarding residency selection? Do current training programs have the flexibility to meet the needs of residents, no matter what their career choice with pediatrics? What areas need greater focus within residency training? Should the length of training remain at 36 months? Based on the available data, the R(3)P Project concluded that more diversity needs to be fostered with training programs. By promoting innovative and diverse approaches to improving pediatric residency education, members of the R(3)P Project hope to enhance learning, encourage multiple career paths within the broad field of pediatrics, and, ultimately, improve patient and family outcomes.

Commentary: training internists for practice focused on meeting patient needs

The author describes the evolution of practice within the broad specialty of internal medicine. This evolution is driven by scientific discovery, emergent patient needs, and market forces. Four ages describe the evolution: the age of the Oslerian diagnostic consultant, the age of the subspecialist, the age of the primary care internist, and the emerging age of focused general internal medicine practice. The author suggests that competence in practice-based learning and improvement linked with evaluation of practice performance throughout a career permits the professions to abandon the notion that valid learning for medical practice occurs only by completing a designated number of months of residency or fellowship training. By applying competency-based standards for specialty certification and maintaining its validity for current practice, boards can provide trainees and practitioners a tool for professional accountability for initial and continuous professional competence. The lifelong learning and evaluation process permits the timely recognition of proficiency acquired in practice. This process engages internists in ongoing guided reflection on measures of performance and provides evidence that they have incorporated new knowledge, technology, skills, and attitudes that align their practice with patient needs. As dialogue with internal medicine stakeholders and customers continues, the author describes how the training standards for certification might adapt to the evolving demands for the specialty practice and how the evaluation of continuous professional development through the maintenance of certification provides an instrument for identifying and recognizing proficiency in providing focused care within the broad discipline of internal medicine.

Medicine cut off from its roots: context matters in medical education

The values and rewards that animate community practice are not clearly visible to those in traditional medical training programs. Flexnerian education explicitly chose to exclude practitioners in favor of full-time faculties. Academic health centers today are organized to take maximum advantage of a reimbursement system that has been described as perverse; perhaps one of the perversities is that the values embedded in the reimbursement system (reimbursement driven by discrete services rather than overall health or function) have been internalized by trainees and their institutions, and other things valuable to patients and communities (longitudinal care, coordinated care, and appropriateness of care) have become invisible.