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