In a healthcare delivery system in which the primary care physician (PCP) and the healthcare organization in which he/she works are capitated, quality of care measures are critical to pushing the physicians and the system as a whole toward continuously stretching for the desired end point, the best healthcare. These measures should be public and factor in the capitated compensation of the PCP and the healthcare organization and in the attraction of patients to the physician and the system. The measures must be both accurate and representative of the outcomes of the most importance in calibrating successful care delivery.
Collection Process Expenses
At this point there has been major emphasis on paying for value with the result being a deluge of measures creating major expense in the collection process. The National Quality Measures Clearinghouse has substantiated 2500 medical performance measures currently in use. Collecting these measures costs the physician an average of $40,000/yr. This expense is compromised by the finding that 35% of the measures are not valid and 28% are of uncertain validity (MacLean,CH et al: Time Out—Charting a Path for Improving Performance Measures. NEJM 378(19);1757, May 10. 2018).
Preventive Medicine Can Save Expense and Lives
The importance of valid, easily extracted measures seems self evident in the move to universal healthcare. This discussion assumes that accuracy and data acquisition are addressed. The concern for this treatise is the reality that the measures established will define the work product of the primary care team and of the delivery system in which he or she works. There is currently a disconnect between what we may expect of healthcare and what is currently defined as healthcare. Discussions about the current status of the healthcare system in America have repeatedly begun by pointing out the shorter average life span and the increased infant mortality in the United States versus the rest of the advanced nations of the world. These statistics are presented as an implied indictment of the quality and availability medical care. The facts are that healthcare, as it is currently defined, “accounts for only 10-20 percent of the overall determinants of health.” (Hester,J: A Balanced Portfolio Model for Improving Health: Concept and Vermont’s Experience. Health Affairs: 37:570, April 2018). This low number is predicated on the de-emphasis of preventive medicine in the current payment system. Of the 18% of gross domestic product currently being spent on healthcare “in 2015, only 3% of health care dollars were spent on preventive services” (PryorK & VolppK: Deployment of Preventive Interventions—Time for a Paradigm Shift. NEJM 378(19):1761, May 10, 2018).
The de-emphasis on prevention is predicated in part on the reality that commercial medical insurance contracts are renewed on a yearly basis, making a longer time horizon illogical from a business perspective, even though in the long term an aggressive preventive medicine effort could be cost effective by improving the health of communities. Additionally, and effecting Medicare patients, “treatments determined by the Food and Drug Administration (FDA) to be safe and effective are usually covered by insurers regardless of their cost, but preventive services have been held to a higher standard: they are often assessed on the basis of whether they generate a positive return on investment and save money in the short term” (PryorK & VolppK:see above). The long term cost effectiveness is not considered.
The Impact of PCP (Primary Care Physicians) Care
With these background facts, consider what would be some of the measures of quality of care for PCPs if prevention is considered of primary importance is diminishing the economic burden of preventable disease. Some measures that come to mind would be a decrease in tobacco use and exposure, blood pressure control, body mass index/weight, overall mortality, cholesterol/lipid level, hemoglobin A1c/glycemic control, and eradication of alcohol abuse. In fact, these measures are eight of the ten target indicators in the Center for Communicable Disease (CDC) program for developing healthy communities called Community Health Improvement Navigator (https://www.cdc.gov/chinav/). These measures focus on what the CDC has discerned as the most important variables effecting community health. This program focuses on not-for-profit hospitals as part of their charitable work requirement by the IRS. There are also concurrent efforts by charitable organizations such as the Robert Wood Johnson Foundation. The state of Vermont has an almost identical program, the Blueprint for Health, a part of an action in six states called Accountable Health Communities (HesterJ: see above). The issue, for the most part, has not viewed the primary physicians as the center of this effort. Intuitively, in a universal healthcare program the PCP should be primarily responsible and the team leader in preventive medical care. The challenge is that achieving the goals of the CDC and other individuals and organizations pushing for more effective preventive care will require much more than the usual office visits, which are currently compensated by fee for service. Effectively addressing changing patients' lifestyle and altering the habits of non-compliant patients requires case managers, social workers, nurse practitioners, and team leaders for group interchanges. These will be in addition to or adjunctive to the chronic disease management teams that will be a central factor in maximizing health in any effective best healthcare model. This increase in personnel will create new costs on the front end with the vision of eventually proving cost effective by creating much improved health.
The point of this discussion is that the measures set for the PCP will define the work product that is produced. Some variant of the measures that the CDC are using for community health are the likely data points that will be used to define the success in a system where the PCP is the central focus of responsibility in the delivery system. If this expanded role is to be achieved much thought must be given to the logistic requirements for success and compensation should be adequate to support the effort. If this expanded approach is not cost effective within some appropriate time frame the approach must be readdressed. Certainly, all the information available at the moment strongly supports the move toward what is being called community health. With universal healthcare the entire population should come under the care of a PCP, which should be a pivotal step toward creating recognition of the US as a leader in international measures of population health.
Setting Up the PCP System for Success
An afterthought: The successful PCP will need a wealth of knowledge and organizational skills. To attract the physician who will be successful in this effort there must be attractive competitive compensation in addition to a diminution in the current level of paper work and in increase in the prestige that the primary care physician has seen eroded over the last few decades.