SHOCK TO THE SYSTEM by Susan L. Kaufman

When it comes to health care in general and primary care in particular, America is not keeping pace with the rest of the world. Shocking as it may be, America is not in the top 30 countries in infant mortality and not in the top 40 in life expectancy at birth. We have a health system organized around acute care.

Those were the opening remarks of Dr. Harvey Fineberg, president of the Institute of Medicine, at a symposium – “Shock to the System: Preparing Primary Care for the Baby Boomers” – that marked the 30th anniversary of Urban Medical, a pioneer in providing patient-centered primary care to the frail elderly and chronically ill in Boston.

Currently, primary care is geared to treat acute, episodic problems in 15 minute patient visits. Fineberg said the team approach, as developed and practiced by Urban Medical, is a system of care that thinks first about the patients’ needs. He said “these understandings are not going to arise in the acute care setting.” And what we need to help solve the crisis in primary care, is to see a “thousand more Urban Medicals around the country.”

Unfortunately, the focus on acute care, “crowds out chronic disease management and preventive care,” according to Dr. Thomas Bodenheimer, of UCSF, and an expert on primary care.

But he also said that primary care, as currently organized and practiced is “not a job that is possible to do.” Studies have shown that 42 percent of primary care physicians say they don’t have adequate time in a 15-minute visit to really listen to the patient and 50 percent of patients say they leave a doctor’s office without understanding what the doctor said, Fineberg added. That is a recipe for bad outcomes all the way around – for the doctor and for the patient alike.

Add to that the critical shortage of primary care physicians that is expected to worsen as the baby boomers age. Nationally, the percentage of third-year residents choosing internal medicine has dropped precipitously from about 50 percent in 1998 to 20 percent in 2007.

So, what can be done? Bodenheimer says macro and micro level solutions should be implemented. For instance, on the macro level, health plans need to invest in primary care and recognize that follow up, care coordination and patient education take time. “All patients can’t be funneled into a 15-minute visit,” Bodenheimer said.

And on the micro or primary practice level, Bodenheimer says care must be redesigned around three areas: panel management (who is getting the care), care management (how that care is being delivered), and coaching (helping patients care for themselves).

Among his suggestions: Have someone in the doctor’s office other than the doctor responsible for managing the patient list…calling them…asking if they are taking their medications, etc.

For care management, Bodenheimer points to the Urban Medical model, in which a team of nurse practitioners, physicians, social workers and non-clinical care coordinators manages all of the patient’s health care needs at all times, through all settings. The team even makes house calls, because their goal is to avoid unnecessary hospitalization and trips to the emergency room and support aging in place.

With coaching, he says there needs to be a partnership between the patient and care team to teach patients and families the skills they need to help care for themselves.

Dr. Robert Master described how Commonwealth Care Alliance, by providing adequate resources to focus on primary care and care coordination, has demonstrated savings in hospitalization and overall costs for dual eligibles. Dr. Jeffrey Kang, the chief medical officer for Cigna Healthcare, acknowledges that for insurers the issue really is how to change the reimbursement system to create a “resource-based” fee system to pay for the “medical home” concept of care.

None of these is a silver bullet that taken alone will solve the problem of meeting the needs of aging baby boomers in a quality and cost effective way. But it is clear that primary care has an important role to play and that these ideas are an important a start toward laying out a roadmap for the future.

Secretary of Health and Human Services, Dr. JudyAnn Bigby and Billie Rosoff-- who herself had a career in health care and now helps care for her husband, Arnold Rosoff, a House Calls patient of Urban Medical-- closed the symposium with personal stories of the difference the patient-centered team approach can make for patient and family alike. “It’s just the most fabulous model. It works for people who have to be in their home or who need to be in their home,” said Rosoff.

Susan L. Kaufman
Executive Director, Urban Medical

This program aired on April 30, 2008. The audio for this program is not available.


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