American Journal of Medical Quality http://ajm.sagepub.com/
The Transformation of Primary Care: Are General Practitioners Ready? Tom Karagiannis, Vittorio Maio, Marco Del Canale, Massimo Fabi, Antonio Brambilla and Stefano Del Canale American Journal of Medical Quality 2014 29: 93 DOI: 10.1177/1062860613513077 The online version of this article can be found at: http://ajm.sagepub.com/content/29/2/93
Published by: http://www.sagepublications.com
On behalf of:
American College of Medical Quality
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513077
research-article2013
AJM29210.1177/1062860613513077American Journal of Medical Quality 29(2)Karagiannis et al
Editorial
The Transformation of Primary Care: Are General Practitioners Ready?
American Journal of Medical Quality 2014, Vol. 29(2) 93–94 © 2013 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860613513077 ajmq.sagepub.com
Tom Karagiannis, PharmD,1 Vittorio Maio, PharmD, MS, MSPH,1 Marco Del Canale, MSc,2 Massimo Fabi, MD,3 Antonio Brambilla, MD,4 and Stefano Del Canale, MD, PhD5 The primary care environment is evolving worldwide to adapt to the emergence of a rapidly aging population with a high prevalence of chronic disease.1,2 Current health care delivery models are not well equipped to manage the complex needs of these patients.1 Often described as the parallel practice model, physicians largely work independently from other providers, preserving their autonomy and creating practices that are traditionally physiciancentric.2,3 This independence at the practice level results in an absence of communication between providers about clinical priorities or approaches to patient care.3 The movement away from parallel practice strives to provide patients increased access, continuity, comprehensiveness, and coordination of care between providers through an innovative practice model referred to as the patientcentered medical home (PCMH).2 PCMH creates a culture of team-based care requiring optimal integration and can be supported by a collection of reimbursement mechanisms. Although efforts to start this transformation are under way, there is limited literature to suggest that general practitioners are prepared or even willing to adopt these new practices. Their perceptions and their respective needs will have to be addressed in order for this movement to sustain long-term success. Historically, physicians maintained a monopoly over medical knowledge, and the public’s belief in their service ethos validated their professional autonomy with patients and other health care professionals.4,5 Over time, this autonomy shaped what has been described as a dual structure; current primary care practice divided by a group of clinicians who work independently from each other and a support staff that focuses on managing patient flow.3 Reorganizing physician-centric practices to facilitate team-oriented integrative care requires an equivalent shift in the professional constructs of all members in the practice. Depending on the circumstances in each medical home, this may mean utilizing midlevel practitioners to their full trained capacity or engaging physicians and support staff in meaningful conversations to create a shared vision and strategic plan for their practice. Refining each member’s unique value to patient care may help general practitioners recognize that they will not be
able to provide the complete range of services their patients need without coordination with other staff. Initial results of small practice transformation have identified lack of physician buy-in to be a significant obstacle to its success.3,6 The reluctance to accept integrated care likely is rooted in what has been called the internal stratification of the physician profession, where physicians responsible for decision making in the health care industry, such as medical directors and clinical research opinion leaders, have conflicting opinions and visions from those held by physicians at the practice level.4 With the implementation of these reforms, general practitioners are left relinquishing certain aspects of their clinical decision making and autonomy, a process referred to as deprofessionalization, while physicians in the upper stratum either maintain or increase their responsibilities from this movement. This process is not unique to primary care reform but rather has stemmed from the adoption of evidence-based medicine, the erosion of the medical space by other health care professionals, and the evolution of performance measures that grade health care quality.5 Current research has shown that reservations held toward PCMHs center on challenges to both their financial and clinical autonomy.7 Providers are concerned that patients will fail to take ownership of their health and anticipate that low per-member-per-month reimbursement will remain prohibitive for many practices. Furthermore, some providers expressed frustration with medical coding and time spent validating clinical decisions through mechanisms such as prior authorization 1
Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, PA 2 Entrypark AB, Stockholm, Sweden 3 Local Health Authority, Parma, Emilia-Romagna Region, Italy 4 Regional Health Care Authority, Bologna, Emilia-Romagna Region, Italy 5 Monticelli Patient-Centered Medical Home, Parma, Emilia-Romagna Region, Italy Corresponding Author: Vittorio Maio, PharmD, MS, MSPH, School of Population Health, Thomas Jefferson University, 901 Walnut Street, 10th Floor, Philadelphia, PA 19107. Email [email protected]
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American Journal of Medical Quality 29(2)
and utilization review. These issues coincide with fears of continued deprofessionalization and suggest that perhaps more time should be spent targeting physicians’ concerns and building communication to address these questions. With little empirical evidence suggesting otherwise, we feel policy makers are underestimating the magnitude of physician acceptance as a barrier to practice transformation. Starting a dialogue between policy makers and providers can be difficult and multiple actions should be taken to facilitate this effort. Future research should examine existing successful PCMHs and identify the determinants that drive physician acceptance of these models. This can lead to understanding how physicians redefine their roles in the new primary care space and what specific reimbursement mechanisms are most effective in directing this change.3 Also, it is becoming increasingly clear that efforts to communicate the redesigned primary care landscape will need to not only reach current physicians but also be reflected in their initial education. Future physicians will need to learn how to effectively integrate themselves with other health care professionals and how to successfully activate patients as stakeholders in the shared decision-making process.8 Additionally, concepts of quality metrics and bundled payments are key components of integrated care and will need to be taught to medical students prior to entering clinical practice. Some of these reforms are currently under way; the Association of American Medical Colleges recently advocated integrating quality improvement courses within medical school curricula; one institution has already incorporated health care quality report cards into their experiential training.9,10 Transitioning reimbursement away from volume-based incentives or fee for service also will require educational reforms targeting strategies that demonstrate proactive population health across the continuum of care. This could include directed coursework that emphasizes the importance of preventive measures to help alleviate the burden of reactive care. These exciting steps can lead to even greater success as it is clear that health care is only scratching the surface of health information technology. As these systems become more fluid and interoperable, we anticipate that innovative performance measures that better reflect individual
patients and outcomes will emerge and replace current indicators. For these reasons we remain cautiously optimistic about the primary care practice revolution and urge researchers and policy makers to work in concert and build a stage for PCMHs to continue to develop and thrive. References 1. Arend J, Tsang-Quinn J, Levine C, Thomas D. The patientcentered medical home: history, components, and review of the evidence. Mt Sinai J Med. 2012;79:433-450. 2. Saltman RB, Rico A, Wienke B. Primary Care in the Driver’s Seat? Organisational Reform in European Primary Care (European Observatory on Health Systems and Policies Series). Maidenhead, England: Open University Press; 2006. 3. Nutting PA, Crabtree BF, McDaniel RR. Small primary care practices face four hurdles—including a physiciancentric mind-set—in becoming medical homes. Health Aff (Millwood). 2012;31:2417-2422. 4. Filc D. Physicians as “organic intellectuals”: a contribution to the stratification versus deprofessionalization debate. Acta Sociol. 2006;49:273-285. 5. Lewis JM, Marjoribanks T, Pirotta M. Changing professions: general practitioners’ perceptions of autonomy on the frontline. J Sociol (Melb). 2003;39(1):44-61. 6. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patientcentered medical home. Ann Fam Med. 2009;7:254-260. 7. Alexander JA, Cohen GR, Wise CG, Green LA. The policy context of patient centered medical homes: perspectives of primary care providers. J Gen Intern Med. 2013;28:147-153. 8. Bernabeo E, Holmboe ES. Patients, providers, and systems need to acquire a specific set of competencies to achieve truly patient-centered care. Health Aff (Millwood). 2012;32:250-258. 9. O’Neill SM, Henschen BL, Unger ED, et al. Educating future physicians to track health care quality: feasibility and perceived impact of a health care quality report card for medical students. Acad Med. 2013;88:1564-1569. 10. Harris S. Improving quality improvement in medical education. https://www.aamc.org/newsroom/reporter/sept10/152742/ improving_quality_improvement_in_medical_education.html. Accessed October 9, 2013.
Downloaded from ajm.sagepub.com at ANADOLU UNIV on May 2, 2014
The Transformation of Primary Care: Are General Practitioners Ready? Tom Karagiannis, Vittorio Maio, Marco Del Canale, Massimo Fabi, Antonio Brambilla and Stefano Del Canale American Journal of Medical Quality 2014 29: 93 DOI: 10.1177/1062860613513077 The online version of this article can be found at: http://ajm.sagepub.com/content/29/2/93
Published by: http://www.sagepublications.com
On behalf of:
American College of Medical Quality
Additional services and information for American Journal of Medical Quality can be found at: Email Alerts: http://ajm.sagepub.com/cgi/alerts Subscriptions: http://ajm.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Mar 3, 2014 What is This?
Downloaded from ajm.sagepub.com at ANADOLU UNIV on May 2, 2014
513077
research-article2013
AJM29210.1177/1062860613513077American Journal of Medical Quality 29(2)Karagiannis et al
Editorial
The Transformation of Primary Care: Are General Practitioners Ready?
American Journal of Medical Quality 2014, Vol. 29(2) 93–94 © 2013 by the American College of Medical Quality Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860613513077 ajmq.sagepub.com
Tom Karagiannis, PharmD,1 Vittorio Maio, PharmD, MS, MSPH,1 Marco Del Canale, MSc,2 Massimo Fabi, MD,3 Antonio Brambilla, MD,4 and Stefano Del Canale, MD, PhD5 The primary care environment is evolving worldwide to adapt to the emergence of a rapidly aging population with a high prevalence of chronic disease.1,2 Current health care delivery models are not well equipped to manage the complex needs of these patients.1 Often described as the parallel practice model, physicians largely work independently from other providers, preserving their autonomy and creating practices that are traditionally physiciancentric.2,3 This independence at the practice level results in an absence of communication between providers about clinical priorities or approaches to patient care.3 The movement away from parallel practice strives to provide patients increased access, continuity, comprehensiveness, and coordination of care between providers through an innovative practice model referred to as the patientcentered medical home (PCMH).2 PCMH creates a culture of team-based care requiring optimal integration and can be supported by a collection of reimbursement mechanisms. Although efforts to start this transformation are under way, there is limited literature to suggest that general practitioners are prepared or even willing to adopt these new practices. Their perceptions and their respective needs will have to be addressed in order for this movement to sustain long-term success. Historically, physicians maintained a monopoly over medical knowledge, and the public’s belief in their service ethos validated their professional autonomy with patients and other health care professionals.4,5 Over time, this autonomy shaped what has been described as a dual structure; current primary care practice divided by a group of clinicians who work independently from each other and a support staff that focuses on managing patient flow.3 Reorganizing physician-centric practices to facilitate team-oriented integrative care requires an equivalent shift in the professional constructs of all members in the practice. Depending on the circumstances in each medical home, this may mean utilizing midlevel practitioners to their full trained capacity or engaging physicians and support staff in meaningful conversations to create a shared vision and strategic plan for their practice. Refining each member’s unique value to patient care may help general practitioners recognize that they will not be
able to provide the complete range of services their patients need without coordination with other staff. Initial results of small practice transformation have identified lack of physician buy-in to be a significant obstacle to its success.3,6 The reluctance to accept integrated care likely is rooted in what has been called the internal stratification of the physician profession, where physicians responsible for decision making in the health care industry, such as medical directors and clinical research opinion leaders, have conflicting opinions and visions from those held by physicians at the practice level.4 With the implementation of these reforms, general practitioners are left relinquishing certain aspects of their clinical decision making and autonomy, a process referred to as deprofessionalization, while physicians in the upper stratum either maintain or increase their responsibilities from this movement. This process is not unique to primary care reform but rather has stemmed from the adoption of evidence-based medicine, the erosion of the medical space by other health care professionals, and the evolution of performance measures that grade health care quality.5 Current research has shown that reservations held toward PCMHs center on challenges to both their financial and clinical autonomy.7 Providers are concerned that patients will fail to take ownership of their health and anticipate that low per-member-per-month reimbursement will remain prohibitive for many practices. Furthermore, some providers expressed frustration with medical coding and time spent validating clinical decisions through mechanisms such as prior authorization 1
Jefferson School of Population Health, Thomas Jefferson University, Philadelphia, PA 2 Entrypark AB, Stockholm, Sweden 3 Local Health Authority, Parma, Emilia-Romagna Region, Italy 4 Regional Health Care Authority, Bologna, Emilia-Romagna Region, Italy 5 Monticelli Patient-Centered Medical Home, Parma, Emilia-Romagna Region, Italy Corresponding Author: Vittorio Maio, PharmD, MS, MSPH, School of Population Health, Thomas Jefferson University, 901 Walnut Street, 10th Floor, Philadelphia, PA 19107. Email [email protected]
Downloaded from ajm.sagepub.com at ANADOLU UNIV on May 2, 2014
94
American Journal of Medical Quality 29(2)
and utilization review. These issues coincide with fears of continued deprofessionalization and suggest that perhaps more time should be spent targeting physicians’ concerns and building communication to address these questions. With little empirical evidence suggesting otherwise, we feel policy makers are underestimating the magnitude of physician acceptance as a barrier to practice transformation. Starting a dialogue between policy makers and providers can be difficult and multiple actions should be taken to facilitate this effort. Future research should examine existing successful PCMHs and identify the determinants that drive physician acceptance of these models. This can lead to understanding how physicians redefine their roles in the new primary care space and what specific reimbursement mechanisms are most effective in directing this change.3 Also, it is becoming increasingly clear that efforts to communicate the redesigned primary care landscape will need to not only reach current physicians but also be reflected in their initial education. Future physicians will need to learn how to effectively integrate themselves with other health care professionals and how to successfully activate patients as stakeholders in the shared decision-making process.8 Additionally, concepts of quality metrics and bundled payments are key components of integrated care and will need to be taught to medical students prior to entering clinical practice. Some of these reforms are currently under way; the Association of American Medical Colleges recently advocated integrating quality improvement courses within medical school curricula; one institution has already incorporated health care quality report cards into their experiential training.9,10 Transitioning reimbursement away from volume-based incentives or fee for service also will require educational reforms targeting strategies that demonstrate proactive population health across the continuum of care. This could include directed coursework that emphasizes the importance of preventive measures to help alleviate the burden of reactive care. These exciting steps can lead to even greater success as it is clear that health care is only scratching the surface of health information technology. As these systems become more fluid and interoperable, we anticipate that innovative performance measures that better reflect individual
patients and outcomes will emerge and replace current indicators. For these reasons we remain cautiously optimistic about the primary care practice revolution and urge researchers and policy makers to work in concert and build a stage for PCMHs to continue to develop and thrive. References 1. Arend J, Tsang-Quinn J, Levine C, Thomas D. The patientcentered medical home: history, components, and review of the evidence. Mt Sinai J Med. 2012;79:433-450. 2. Saltman RB, Rico A, Wienke B. Primary Care in the Driver’s Seat? Organisational Reform in European Primary Care (European Observatory on Health Systems and Policies Series). Maidenhead, England: Open University Press; 2006. 3. Nutting PA, Crabtree BF, McDaniel RR. Small primary care practices face four hurdles—including a physiciancentric mind-set—in becoming medical homes. Health Aff (Millwood). 2012;31:2417-2422. 4. Filc D. Physicians as “organic intellectuals”: a contribution to the stratification versus deprofessionalization debate. Acta Sociol. 2006;49:273-285. 5. Lewis JM, Marjoribanks T, Pirotta M. Changing professions: general practitioners’ perceptions of autonomy on the frontline. J Sociol (Melb). 2003;39(1):44-61. 6. Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patientcentered medical home. Ann Fam Med. 2009;7:254-260. 7. Alexander JA, Cohen GR, Wise CG, Green LA. The policy context of patient centered medical homes: perspectives of primary care providers. J Gen Intern Med. 2013;28:147-153. 8. Bernabeo E, Holmboe ES. Patients, providers, and systems need to acquire a specific set of competencies to achieve truly patient-centered care. Health Aff (Millwood). 2012;32:250-258. 9. O’Neill SM, Henschen BL, Unger ED, et al. Educating future physicians to track health care quality: feasibility and perceived impact of a health care quality report card for medical students. Acad Med. 2013;88:1564-1569. 10. Harris S. Improving quality improvement in medical education. https://www.aamc.org/newsroom/reporter/sept10/152742/ improving_quality_improvement_in_medical_education.html. Accessed October 9, 2013.
Downloaded from ajm.sagepub.com at ANADOLU UNIV on May 2, 2014
