The BASIC CARE feature of our model represents the most important part of the function of the new plan. Basic care is that care which covers every citizen from birth and consists of high quality Primary Care which follows guidelines established by respected medical organizations. It includes prevention and treatment of serious societal problems such as drug abuse, obesity, diabetes, and education of non-compliant patients about better health. It is funded from employer-funded health premiums, funds of individuals who are self-employed, and public funds for those who are unemployed or the working poor who are subsidized according to ability to pay. Primary Care physicians provide high quality care, guide referrals to specialists and hospitals, and coordinate care. Clinical effectiveness and efficiency will be measured by a comprehensive Electronic Health Record (EHR) (see Figure 1)
All citizens are free to choose a physician in any of the group practices as long as he or she has openings; otherwise they may be assigned to another provider or choose another group.
Who Are Primary Care Physicians (PCPs)
Primary Care Physicians include Family Practice, General Internal Medicine, Pediatrics, and Geriatrics. They are involved chiefly in office practice, providing continuing care of a variety of medical issues not only in diagnosis and treatment of disease processes, but also in guiding patients to healthy lifestyles and disease prevention. When appropriate, they refer patients to specialists such as surgery, cardiology, or other highly specialized services.
PCPs are guided by Standards of Practice provided by their respective professional organizations, as well as recommendations by the National Academy of Medicine, the U.S. Preventive Services Task Force, The Department of Health and Human Services, among others. Physicians are expected to work successfully with care teams including nurses, physician extenders (nurse practitioners and physician’s assistants), pharmacists, social workers, physical therapists, and others. They are also expected to communicate effectively with patients in person and by other modalities and to have interpersonal skills that lead to satisfaction by patients and families.
In our healthcare model, PCPs are central to the success of treating all Americans, helping to control unnecessary costs, and working with care teams to assist uneducated poor or uninformed citizens with socio-medical issues.
Present Problems in Primary Care
An important feature of PCP practice in the present system is that they have to serve large numbers of patients, work under grueling paperwork requirements in order to be reimbursed, and are paid less than most other physicians. Presently there are not enough medical graduates entering Primary Care to make this possible. Reasons for this include the prestige of being a procedural specialist, often with much greater income, and the need to pay off student debts frequently over $100,000.
Organization of Basic Care Practices
In our BASIC CARE plan, groups of primary Care Physicians would link together to be able to provide teams of providers including physician extenders, health educators, and others to care for patients who choose their group practice. These practices could include one type of providers such as Family Medicine, Pediatrics, or Psychiatry, or might be a large group including family practice, general internal medicine and Geriatrics together. This group would be at financial risk if they do not succeed with excellent results, patient satisfaction, and economic efficiency. It is less likely that very small groups will accept the risk of failure due to small numbers in the risk pool.
For instance, a group of 20-100 Primary Care physicians might include Family practice, pediatrics, general internists, and geriatricians. Their capitated patients would include health-adjusted payments to the practice determined by age, chronic disease, and physical complications such as obesity, smoking, and drug abuse. The health adjustment capitations would be established by the payment organization. Each year data from the Electronic Health Record (EHR) would determine whether the physicians practice is producing excellent required outcomes, and whether the practice made cost-effective decisions on ancillary testing and referral to specialists. If the results were favorable, the capitation rate for the group would continue, or if the mix of patients changed appreciably, or if certain established standards were not followed, there could be a change in the next year’s capitation.
A larger group would be more able to include practice extenders such as nurse practitioners or physician’s assistants and patient educators and social workers. Teams of practitioners would be more efficient and could focus on needy patients who need help in understanding their responsibilities of taking medicines and living healthy lifestyles. Since 86 % of healthcare cost is for chronic disease, multidisciplinary chronic disease management teams would be an integral component of healthcare delivery. Additionally, care managers could address the issues of non-compliant patients and patients with an unhealthy lifestyle.
Pharmacists could easily take part in the team, and their costs would be supported by the profits of the parent pharmacy. Basic dental care would be valuable, but since dental care is not covered by Medicare and poorly covered by dental insurance, this needs more consideration.
An important feature of cost control, a responsibility of the PCP, would be referrals to specialists, hospitals and medical device vendors. Referrals to specialists would be facilitated by readily available data from the EHR which would help the PCP in choosing a specialist with good care qualities, good results, and reasonable cost. Hospital data would also allow the PCP to choose a hospital with high quality scores and most reasonable costs.
An alternative approach would be that a Primary Care group would contract with specialists whom they believe would provide cost-effective care. These would be partners in the group. Otherwise the various medical and surgical specialist would form their own groups who would, in a competitive marketplace, attempt to show that their group would give high quality care and the best cost-reduction.
In the special case of providers in small communities or rural areas, groups of providers in the region could form a group in order to share the risk of very costly patients. Another alternative would be a special capitation if an individual is willing to establish a solo practice with a number of patients typical of such a practice and also followed by the EHR.
In the best consideration of a private marketplace, Primary Care physicians would accept the risk of failure, hoping to profit from professional success and cost savings. This would indicate an alignment of incentives that characterizes the best of a capitalistic system which Americans find acceptable.
The result would be a major lessening of healthcare costs and better healthcare for all Americans.
What Changes in Primary Care Are Necessary?
These should include:
- Increasing income for PCPs
- Forgiveness of student debt over a few years
- Replacing the present fee-for-service incentive to seek more and more revenues with a capitated incentive to greater value and cost control
- Active recruitment of top students into primary care practice
- Promoting primary care as a pivotal part of the solution of our healthcare crisis ]
- Increased use of physician extenders and formation of practice teams to facilitate services.
All of these things are possible with better recognition of the present healthcare crisis and the unsustainable increases in healthcare costs. Also required is the will of medical educators to change training programs to enhance PCP training and encourage top students in primary care. We believe that wide distribution of our healthcare model, and the debate it generates will advance the goal of change.