Many of us at The Commonwealth Fund, along with numerous colleagues elsewhere, spend a lot of time analyzing how best to expand health care coverage to all Americans. We feel passionately about the need to address this difficult problem in whatever way turns out to be most realistic and sustainable. But while we work hard on how to expand coverage, we spend an increasing amount of time thinking about the kind of care provided. Because even if you are well insured, you may not be able to get the care you need, when you need it, in a way that works for you.
I experienced this problem some years ago when I couldn't get an appointment to see my primary care doctor for what turned out to be pneumonia. The office receptionist told me there were no open appointments for eight weeks, even though I felt sicker than I had ever felt in my life. I found another physician and have been a loyal patient for a decade. But I didn't find the route to my new physician easy or pleasant.
Compare this with another primary care system, Denmark's, which I observed firsthand not long ago. Denmark has an unusual system that blends primary-care patient panel fees and fee-for-service payment. Each physician has an enrolled patient population of about 1,500. Physicians own their practices, many of them small group arrangements. The system is set up to handle same-day appointments and walk-ins. Electronic prescribing networks linking physicians and pharmacies have been in place since the late 1990s. Physicians still make the occasional house call. When the doctor's office closes, an "off-hours service" kicks in, staffed by physicians who handle patient questions by telephone, informed by computerized patient health registries, electronic prescribing, and clinics set up to promote off-hours primary care. Off-hours telephone consulting is reimbursed and the patient's main doctor briefed on the off-hours physician's advice and care.
Real Patient-Centered Medicine
I call this truly "patient-centered" medicine, and I'm a convert. I'm not suggesting the Danish system is perfect—Danish hospitals have a long way to go to meet American standards and the waiting times for specialist care would be intolerable to most of us, for example. Nor do I think the Danish health care financing and delivery system, which no doubt is what allows the primary care system to do so much for patients, can be transferred to this country easily or perhaps at all. But there is ample evidence that patient-centered care can be, if not achieved, as least vigorously pursued in this country right now.
The Institute of Medicine has included patient-centered care as one of six domains of quality. Assessing patient experiences with physician care is not as well developed, but it can be done. Dana Safran, Sc.D., of Tufts–New England Medical Center has conducted surveys of patient experiences with primary care on 11 summary measures covering two broad dimensions of patients' experience: quality of interactions with primary care physicians and organizational features of care (access, visit-based continuity, integration of care, clinical team, and office staff). Safran and her colleagues, in part with Fund support, have demonstrated that valid and reliable measures of patients' experiences with individual physicians and practices can be obtained.
Other leading researchers have shown that the benefits of patient-centered primary care include patients' adherence to medical advice, improved clinical status, loyalty to a physician's practice, and reduced malpractice litigation. But from an economist's point of view, patient-centered primary care is important in and of itself—as a reflection of the patient's utility gained from the receipt of the care. One of the basic tenets of economics is that consumption of goods or services should maximize the utility or satisfaction of consumers as perceived by those consumers. From this perspective, whether care given to patients maximizes their satisfaction for the revenue spent should be the ultimate test of whether the health system is doing a good job. A transformed primary care system would ensure that all patients have access to the kind of care that works for them.
Quality is often defined as providing the right care in the right way at the right time. But a patient-centered vision would define quality as providing the care the patient wants in the way the patient wants at the time the patient wants it. Since both patients and physicians want good health outcomes, sometimes these goals are identical. Economists have talked about the physician as the patient's agent—providing the care the patient would want if the patient had the information that the physician has. But increasingly patients want direct access to that information and the ability to be active partners in their care. That will require listening to patients much more and reorienting primary care practice to provide care that works for patients.
A Wish List for Patient-Centered Care
In a recent article in the Journal of General Internal Medicine, colleagues Stephen C. Schoenbaum, M.D., Anne-Marie Audet, M.D., and I proposed, for research and discussion, that a patient-centered primary care practice have the following characteristics:
- Team-based care—doctors, nurse practitioners, nurses, and others as needed, including social workers, nutritionists, exercise physiologists, and behavioral health specialists.
- Advanced access—ease of making an appointment, timely appointments, short waiting time in office, e-mail visits and electronic prescription refills, timely response to e-mails and telephone calls, efficient use of doctors' and patients' time, off-hours service with prompt access to medical advice and care.
- Patients as informed and engaged partners in their care—shared decision-making, assistance with self-care and behavior change, information on condition/treatment options/treatment plan, patient education, anticipatory guidance and counseling for parents on child development issues.
- Information technology and smart office systems—patient reminders/alerts and patient access to electronic medical records and treatment plan, streamlined scheduling and medication refills, monitoring of adherence to recommended care, decision support for physicians, longitudinal charts on risk factors/health outcomes/use of services, and specialist reports.
- Coordination of care—coordination of specialist care, prompt feedback, systems to prevent errors that occur when multiple physicians or sites are involved in care, post-hospital follow-up and support, links to community resources.
- Patient feedback on experiences with care, such as patient-centered care surveys.
- Public information on practice performance—information on how to choose physicians and physician directories (including credentials, office locations, hours of practice, age, gender, race, quality of care, patient experiences with clinician, peer assessment of practices) that meet the National Committee for Quality Assurance standards for online physician directories.
- Professional recognition and appropriate financing of primary care to reward excellence in patient-centered primary care.
Many of these elements of patient-centered care exist today, but few practices embrace them all. Similarly, many of the systems and tools that could make this transformation a reality also exist today, but few practices are using them. This is not because of clinician intransigence or indifference. I know primary care physicians often feel under siege, underappreciated, and overworked. So it is important to address the financial issue head-on. I would strongly urge the adoption of a Danish-style "medical home," with a related monthly patient-panel fee combined with the current fee-for-service payment system. There are major issues to be resolved as to the appropriate level of a "medical home" monthly fee and how it would be financed—as an add-on or by offsetting savings in specialty care. But we should think about the option.
One way it could work is that primary care physicians would charge a "medical home" monthly fee in exchange for serving as a patient-centered care practice with the characteristics outlined above, including e-mail visits, reminders, access to electronic medical records, same-day appointments, and other patient-centered services. Demonstrations could test the concept and a business case could be developed with appropriate analysis of the enhanced services. Research also would be needed to document the impact of this patient-centered model of primary care—on quality of ambulatory care; offsetting savings from reduced specialty care, emergency department, and hospital utilization; and, most important to me, patient satisfaction and continuity of care.
It would be important that Medicare, Medicaid, and the State Children's Health Insurance Program take the lead in paying for these medical home services. Private insurers likely would follow, although many patients may well be willing to pay the charge directly. I view this as quite different from the "boutique" medicine concept that some physicians now practice out of frustration with the current financing and delivery system. It would be available to all patients, at a relatively modest fee, provide services of real value that are not now routinely provided in primary care, and potentially be covered by insurance. Health care organizations also could help by providing training for primary care practices on methods of improving quality of care.
But to make this vision of primary care a reality takes champions—primary care leaders with a commitment to professionalism, quality improvement, and patient-responsiveness. The Commonwealth Fund is contributing by launching a new Patient-Centered Primary Care initiative to help make quality, patient-centered care a reality. We hope all primary care physicians will consider themselves key partners in this effort.
As always, I'd like to hear from you. Send your feedback to [email protected].
