Are Micro Practices the Ideal Solution for Primary Care?

The Institute of Medicine’s 2001 report Crossing the Quality Chasm reaches the conclusion that the US healthcare system is incapable of delivering the care we need despite spending more money per capita on healthcare than any other developed country. There are many initiatives aimed at addressing this problem, but most appear unlikely to succeed:

• Consumer-driven healthcare sounds nice, but on the street it looks more like simple cost shifting to the consumer. I suspect the average consumer will skip preventive care until something goes seriously wrong mirroring the very root of low-quality/high-cost US healthcare.

• Pay for performance (P4P) is meritorious in theory, but in practice may only shift money to high-performing organizations while effecting no meaningful change in quality.

• Electronic health records (EHR) might make current practice more expensive and slow or, if coupled with workflow improvement, may add efficiency, but in and of themselves they do nothing to improve care or outcomes.

There is a significant body of literature documenting a positive relationship between primary care and quality and an inverse relationship between primary care and cost. With this evidence, one could argue for increased funding for primary care as a simple solution, but the Crossing the Quality Chasm report and other studies suggest we don’t need more of the same kind of care currently delivered by our healthcare system.

The Ideal Micro Practices project (IMP) was launched in January 2006 with funding from the Physicians’ Foundation for Health Systems Excellence to find out if it is possible for practices to learn how to deliver effective primary care, and if so, make the case that increased funding for truly effective primary care can enhance population health, improve patients’ healthcare experience, and reduce total healthcare costs.

Testing 1, 2, 3

The Ideal Micro Practices model of physicians relying on information technology in place of staff in order to reduce overhead and have more time for patient care is reasonably effective. Participants in the project devote only 35% of revenue on average to overhead. By nature of being small, personal practices, they tend to have high scores in key patient experience-of-care metrics. Our goal has been to identify and demonstrate the practice attributes that lead to improved outcomes. We see them in Ideal Micro Practices and are testing their applicability in larger practices.

Many practices in our project are willing and able to adopt behaviors that lead to effective primary care, including:

• Offering unfettered access patients report that there are no barriers to them when they want or need care.

• High continuity patients know who to turn to when they have medical needs. In a pilot study, we’re finding that 25% of patients receiving primary and specialty care lose track of “who’s in charge” of their care and experience a 100% increase in hospital admission.

• Highly efficient care patients experience no waits or delays during the office visit.

• Move beyond compliance—practices work to determine what really matters to patients, in addition to the usual approach to finding out “what’s the matter.”

Because practices in the IMP project offer patients the use of information technology as part their efforts to provide “patient-centered collaborative care,” their patients are much more likely than the national average to report having the information they need to manage their conditions (illness and wellness), and the confidence to use that information to manage their conditions.

The IMP project has demonstrated a simple curriculum and dissemination model that can reach solo independent practices across the US. Participants have demonstrated the ability to do the necessary work in order to deliver improved results. The IMP project is a measurement system that is within the technical and financial grasp of any practicing physician.

Building a Foundation

If you find these concepts appealing, there are simple steps any interested clinician can take. Go to this site (scheduled to be up and running in August 2007) and click on “Cool Tools” to access a practice self-assessment tool and a patient satisfaction survey. Complete the self-assessment and give the patient survey to 30 consecutive patients. Tally the results to see if your practice has structural problems (difficulty with access, efficiency issues, etc) and find out whether your patients with chronic conditions have the resources they need to manage those conditions (very good information, confidence, etc).

What you gain from this practice “biopsy” is simple information that tells you what is working well in your practice and where you need to focus your efforts to improve. You can go to the Institute for Healthcare Improvement website to access a wealth of practice improvement information. You can also join one of the upcoming cohorts of the Ideal Micro Practices project (the next cohort launch is scheduled for early fall 2007).

While all of the above leads to very nice improvement in quality of care and patient experience of care, the greatest reduction in total cost of care will only come from coordination of care across the continuum. The IMP project is learning how to engage in care coordination.

This professionally rewarding model will not spread very far without significant changes in the financing of healthcare. Some doctors are willing to go out on the ledge of true innovation in the delivery of care, but they do so at their own financial peril. Healthcare involves so much more than just patient visits/encounters or procedures performed, yet physicians’ behavior is organized almost entirely around these revenue drivers. Many of the behaviors associated with effective primary care are uncompensated, making it difficult if not impossible for most practices to engage in the work.

The poisonous financial environment for primary care leads to a supply shortage as smart medical students and the current primary care work force seek greener pastures the former are opting in greater numbers to pursue highly compensated subspecialty work, while the latter are bolstering their practices with extra services such as labs, Botox, and laser aesthetics. Some primary care practitioners resort to focusing just on well-to-do patients. Others are opting to leave healthcare altogether. To attract good doctors into effective primary care, we need greater compensation for doing the right work.

The status quo must be off the table and we must create a payment system that rewards effective primary care. Business leaders, patient advocates, physicians, and any other natural ally must work together to overcome the immense inertia invested in the status quo. Physicians must stand up for the health of the populations we serve.