A 2020 Vision of Patient-Centered Primary Care

In the Literature

The concept of patient-centered health care is beginning to take hold. Increasingly, patients expect physicians to be responsive to their needs and preferences, to provide them with access to their medical information, and to treat them as partners in care decisions. But despite being named one of the key components of quality health care by the Institute of Medicine, "patient-centeredness" has yet to become the norm in primary care. In the article, "A 2020 Vision of Patient-Centered Primary Care" (Journal of General Internal Medicine, Oct. 2005), the authors offer their perspective on what it will take to achieve this ideal.

The plan advanced by The Commonwealth Fund's Karen Davis, Ph.D., Stephen C. Schoenbaum, M.D., and Anne-Marie J. Audet, M.D., builds on an earlier essay, "A 2020 Vision for American Health Care," a broad prescription for improving insurance coverage, access to care, and quality in the United States.

Attributes of Patient-Centered Care
In the new article, Davis and her colleagues set out seven attributes of patient-centered primary care:

1. Superb access to care. Patients can easily make appointments and select the day and time. Waiting times are short. E-mail and telephone consultations are offered. Off-hours service is available.
2. Patient engagement in care. Patients have the option of being informed and engaged partners in their care. Practices provide information on treatment plans, preventive and follow-up care reminders, access to medical records, assistance with self-care, and counseling.
3. Clinical information systems that support high-quality care, practice-based learning, and quality improvement. Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments.
4. Care coordination. Specialist care is coordinated, and systems are in place to prevent errors that occur when multiple physicians are involved. Posthospital follow-up and support is provided.
5. Integrated and comprehensive team care. There is a free flow of communication among physicians, nurses, and other health professionals. Duplication of tests and procedures is avoided.
6. Routine patient feedback to doctors. Practices take advantage of low-cost, Internet-based patient surveys to learn from patients and inform treatment plans.
7. Publicly available information. Patients have accurate, standardized information on physicians to help them choose a practice that will meet their needs.

Patient-Centered Care Already Exists
To the many primary care physicians feeling pressed for time and constrained financially, the authors acknowledge that this list may appear overwhelming. But according to the authors' analysis of the Commonwealth Fund 2003 National Survey of Physicians and Quality of Care, nearly all primary care practices already incorporate some of the attributes of patient-centered care, and about one-fifth of practices incorporate the majority of them. For example, three-fourths of primary care physicians now make same-day appointments available. Seventy percent of primary care physicians receive timely feed-back from specialty referrals. About half have patient reminder systems. And two of five are able to create patient disease registries with ease.

Other patient-friendly practices are less common, however. For instance, only 16 percent of primary care physicians communicate with their patients via e-mail, even though the cost is minimal. This may have more to do, say the authors, with a physician culture that works against sharing information and providing transparency. More resource-intensive practices, such as use of electronic medical records or patient surveys, are relatively rare; only about one-fourth and one-third of physicians, respectively, are currently employing them.

Lessons from Abroad
In trying to incorporate the components of patient-centered care, U.S. primary care practices can learn from the experiences of other countries, the authors say. In Denmark, for example, each primary care physician is responsible for about 1,500 patients. This model—known as a "medical home"—helps to lay out the rights and responsibilities of both patient and physician and creates a seamless system of care. Physicians are paid through monthly per-enrollee fees as well as fees for individual services. Additional patient-centered attributes include same-day or walk-in appointments, an electronic prescribing system connected to local pharmacies, and an off-hours telephone service staffed by physicians with electronic access to patients' health information.

Meanwhile, the United Kingdom's new general practitioner contract allows physicians to earn bonus payments of up to 30 percent of their income for providing certain aspects of patient-centered care. This system not only rewards physicians for improving clinical performance, but also for conducting patient surveys and acting feedback to improve care.

Policy Recommendations
Ensuring that all Americans—whether enrolled in public or private health plans, or uninsured—have a medical home would be an important first step toward creating a patient-centered care system, the authors say. They suggest that this model of care could be supported through a Danish-style, blended per-patient and fee-for-service system. Patient-centered care practices could receive a fixed monthly fee for a package of services, including e-mail visits, reminders, access to electronic medical records, and provision of easy access to care when needed.

In addition, pay-for-performance contracts similar to those employed in the U.K. could encourage primary care practices to measure and improve their quality of care by conducting surveys of patient experiences with care, among other methods.

Finally, the authors call for demonstrations to test the viability of such models and develop a "business case" that documents costs and offsetting savings. "With appropriate leadership and policy changes," they conclude, "all Americans could receive primary care that is truly patient-centered."

Facts and Figures:

• About one-half of all primary care physicians have patient reminder systems, although only one-fifth of these systems are automated.
• About one-fourth of physicians currently use electronic medical records, and 16 percent communicate with patients via e-mail.
• Seventy percent of primary care physicians receive timely feedback from specialty referrals.