thoughts on the future of primary care - council of state...
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Thoughts on The
Future of Primary
Care
Dr. William Rowley Institute for Alternative Futures
1
Impact of Primary Care
• States that have more primary care have better health
outcomes – lower mortality, better self-reported health
• 32% of U.S. physicians in primary care – family medicine,
general internal medicine, pediatrics
• PC doctors more than 50% in most other countries
Starfield B. Contribution of Primary Care to health Systems and Health. The Milbank Quarterly 2005;83:457-502. Chan CH. Primary care physician workforce and Medicare beneficiaries’ health outcomes. JAMA 2011;305:2096-2105. Juva T. Family medicine gets renewed focus as need grows. The Journal News (Westchester, NY), 10/5/11.
• “Adequate features of 1o care” produced fewer ER visits,
better preventive care, report being healthier
• Areas with higher Medicare 1o care had 5% lower mortality,
9% fewer hospitalizations; costs similar
Demand and Supply
• Accountable Care Act goal of providing health care for an
additional 32 million
• Almost half of adults have at least one chronic disease
• Will need about 45,000 more PC doctors by 2020
• Med school enrollment increasing 30% 2002 – 2016
• More students going into primary care
• Physician assistants increased 200% last decade
• Nurse practitioners expected to increase 23% in 10 yrs
• Many other options for medical assistants
• Probably take 10 years to make dent in the shortage
Institute for Alternative Futures. Primary Care 2025: A Scenario Exploration. http://www.altfutures.org/primarycare2025. Kliff S. Mo’ doctors, mo’ money, mo’ problems?, Washington Post 5/4/12. Sataline S. Medical Schools Can’t Keep Up, WSJ 4/12/10. Helfand D. Physician assistants see big growth in U.S. Los Angeles Times, 9/8/11. Best Jobs in America: Nurse Practitioner. http://money.com/magazines/moneymag/bestjobs2009/snapshots/4.html
• Seniors utilize about 75% more primary care
Experience of Care Providing a care experience that is patient and
family centered, compassionate, convenient,
equitable, safe and always of the highest
quality. Also important is providing the right
evidence-based care well without
complications.
Population Health Reducing the generators of ill health by
encouraging healthy behaviors and
decreasing the likelihood of illness through
focused prevention and the development of
increased resilience.
Per Capita Cost Creating value by focusing on quality,
eliminating waste, and reducing
unwarranted variation; considering the total
cost of care over time, not just the cost of
an individual health care activity.
Creating Better Health Care
Consensus on Shared Responsibility
A national dialog for under-standing and
consensus on big issues.
4
The Triple Aim
Berwick DM. The Triple Aim: Care, Health, And Health. Health Affairs 2008;27:759-769.
A Patient-Centered Medical Home
5
Accountable team
leader
Ongoing
Monitoring &
support
Electronic records
with long-term data
New payment systems with
incentives for outcomes
Life-long continuity of
comprehensive prevention & care
Easy access to care
Patient-
centered
care
Education,
coaching,
shared
decision-making Entire health system of specialty
care services (ACO)
Focus on prevention
and healthy living too
AAFP, AAP, ACP, AOA. Joint Principles of the patient-centered medical home. The Patient-Centered Primary Care Collaborative. Published February 2007.
Evidence-based continuity
of care by collaborative
team
Quality of Life Able to do your Job
Well-Being “Thrive”
Broad View of Population Health
Health & Function
Morbidity & Death
States of Health
Medical Care &
Self-Care
Disease & Injury Burden
Intermediate Outcomes
Behavioral Risk Factors
Resilience
Physiological Risk Factors
Individual Risk Factors
6
Determinants & Factors
Physical Environment
Prevention & Health
Promotion
Genetic Endowment
Socio-economic
factors
Dis
par
itie
s
Redundancy Self-healing
Focused Secondary Prevention &
Behavior Change
Primary Prevention
Slide by Dr. Rowley based on McGinnis JM, Williams-Russo P, Knickman JR. The Care For More Active Policy Attention To Health Promotion, Health Affairs 2002;21:78-93
Empowering Individual Self-Care
Noninvasive monitoring
Wireless capture Text prompts
Personal health record
Facilitated Disease Network
Virtual Care
7
Digital Health Assistant
Auto-Care
Health System Monitoring
Prospective Medicine
8
Biomonitoring: genes proteins, cancer
cells metabolism, emotions…
Real-time tracking
of my health status
Profound knowledge of
effective prevention and
intervention
• Predictive
• Preventive
• Personalized
• Participatory
• Focused on pre-disease
Create the ideal conditions for
my body to maximize health
Changing Delivery Systems
• Fewer individual & small group practices
• More large medical groups
• Progressively more integrated systems, ACOs
• Will governments’ role be bigger or smaller?
• Some high end concierge practices
• More Community Health Centers
• More innovations: retail clinics, cybercare…
• At lest some will rely on self-managed health
• All these options can incorporate patient-
centered primary care principles
Changing Reimbursement Systems
• Declining Fee-For-Service
• Increasing global/capitated/bundled payment systems
• Incentives: pay for performance, outcomes, value
• Value-based insurance design
• Increasing consumer directed (high deductible ins./HSA)
• More out of pocket costs
How will these shift:
• Employer provided insurance?
• Individual insurance?
• Medicaid, Medicare?
• Uninsured and underinsured?
Value = Quality/ Costs
Challenges Ahead
• We will require a robust primary care capacity to achieve
the Triple Aim in creating healthy citizens
• The cultural shift to advanced primary care will be tough
for the health care industry and patients
• Training enough manpower will take time and effort
• Access to equitable care for all will be daunting
• Finding resources and controlling costs will be hard
• Learning how to achieve behavior change may be our
biggest challenge
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