The May 17 New England Journal of Medicine 200th Anniversary edition article The Evolving Primary Care Physician highlights key structural, financial, and cultural challenges that confront primary care in the United States. Some of these include training and education that emphasizes ever greater subspecialization, reimbursement that rewards volume versus value, and an increasing reliance on testing versus well-honed history taking, physical diagnosis, and counseling and coaching of patients and their family members/care givers.
The article touches upon research conducted by Christine Sinsky and Thomas Bodenheimer, supported by the American Board of Internal Medicine Foundation, in which they visited and observed 23 primary care practices. A compelling distillation from Dr. Sinsky:
What I’ve really seen is a lot of waste within the health care system at the level of utilization of physician skills. I think two thirds of many [primary care] physicians' days are spent on documentation, administrative tasks, paper work completion, rote inbox management, data gathering, and data entry. It’s something that is hard to recognize when you’re the one doing it.
To re-invigorate primary care, training needs greater emphasis on history taking skills, motivational interviewing, physical diagnosis, synthesis of information, more judicious use of testing and imaging, and engaging patients in their health care.
For primary care clinicians to enjoy professional satisfaction and improve population health management, and to reduce primary care clinician time on administrative functions, team-based care is a powerful prescription for positive change.
Douglas Kelling, a general internist in Concord, North Carolina, is profiled in the article as a successful example of transformation to team-based care. Kelling’s personal analogy is to make medical care “more like NASCAR with the doctor as the driver and other team members responsible for the fuel and tires.”
Dr. Kelling’s practice is effective caring for a large population, including patients with multiple chronic conditions.
Emerging health plan and CMS models that provide payments for care coordination and outcomes-/ performance-based payments will result in many new primary care-anchored teams through the country.
Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.
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