Designing A 21st Century Approach to Primary Care

John R. Griffith, PhD, University of Michigan; Kyle L. Grazier, PhD, University of Michigan; Scott B. Ransom, PhD, University of Michigan - October 13, 2010

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When it comes to primary care, neither patients nor practitioners are satisfied with current trends.  A new vision of primary care—one built on a clinically and economically sound foundation—offers substantial benefits to both physicians and their patients.

Although primary care is expected to be  safe, effective, patient-centered, timely, efficient, and equitable, it often is not.  Research indicates that patients’ overall satisfaction with primary care is limited and that substantial numbers of primary care practitioners report dissatisfaction with their field and concerns about its future.  Today’s primary care system is also troubled financially.

A paper by John Griffith, Kyle Grazier, and Scott Ransom proposes to remedy these problems with a new vision of primary care.  They reference successful business models as a way to revolutionize primary care via improvements in marketing (both to patients and caregivers), logistic support functions, clinical practice functions, and financial management.  The authors believe that, to achieve success, the new primary care system must:

• be responsive to patient needs so that patient-customers return when appropriate and recommend the provider to others;
• create a desirable “product” by providing benchmark level care against IOM goals and seeking continuous improvement in treatment quality and effectiveness;
• retain and attract caregivers by “delighting” practitioners in the areas of personal and professional satisfaction with their careers;
• provide care that maximizes value and effectively manages referrals for patients who need specialty care;
• use financial incentives to reward providers and patients for constructive behavior.
• be implemented without substantially disrupting current patient care or a physician’s practice.

The authors’ plan for primary care offers patients an expanded network of prevention and care opportunities that go beyond the traditional doctor’s office and emergency department.  Care would be accessible through multiple mechanisms (such as voice phone, email, websites, and geographically and temporally convenient sites), but would also be coordinated so that patients are directed along the most clinically effective path.

In the proposed new model, primary care physicians would use information technology, local nurse clinicians, and midlevel providers to optimize interactions with all patients while serving as the primary consultants for patients with complicated care needs.  These physician-managers would assure the adoption of contemporary and evidence-based care for all patients and oversee an appropriate continuum of care from outpatient to inpatient to hospice.

The authors envision clinical management that would use technology to optimize prevention and treatment.  Standardized electronic medical record would reduce errors and coordinate multiple caregivers while wireless and hand-held devices would provide faster, more extensive communication.  Evidence-based protocols and measures would optimize the management of common chronic diseases.  Increased training and “service excellence” approaches would improve the quality of the patient experience and enhance receptiveness to clinical advice.

Although financial gain for the twenty-first century primary care practice would occur through improved efficiencies in logistic and business office functions, most financial gain would come as a result of revised clinical care—improved prevention, reduced unnecessary and futile treatments, improved management of chronic disease, and improved patient satisfaction with service and reliability.

Finally, the authors provide practical strategies and a checklist for existing systems who want to adopt a twenty-first century approach to primary care.  Included in their list of “must haves” are:

• Dedicated and experienced primary care physicians
• A dedicated and professional midlevel and nurse provider network with knowledge of the community, its culture, and its resources.
• A network of able, dedicated specialists willing to provide compensated on-line and phone consults to primary care physician and/or midlevel providers.
• An established (or targeted) large patient population. Integrated and longitudinal electronic medical records with evidence-based alerts and reminders for both providers and patients.
• Web-based availability and strategy for interactive patient-specific and directed health inventories, screening and treatment reminders, and health education.
• Sources for continually updated and reliable evidence-based materials and reminders.
• Information technology tools used to regularly review client population for compliance with all patient-specific screening, diagnostic, and treatment recommendations.
• Patient-level financial incentives (or disincentives) to have all non-specialty services through primary care providers and to visit specialists only for predetermined services.
• 24-hour phone and e-mail connectivity for immediate and convenient patient access.
• Access to high quality hospitals with continuous on-line connectivity and information sharing regarding all patient care activities.
• Financial stability with a strong and realistic business plan.