I was asked to prepare for a discussion on what the role of primary care in our Academic Health Center should be. This will happen tomorrow. I have spent the better of 2 days trying to decide exactly what that role is.

I’ve decided to begin with the definition that the American Academy of Family Physicians uses:

  • Primary care providers offer a wide range of services including diagnosis and treatment of acute and chronic illnesses, disease prevention services and patient education.
  • A primary care practice serves as the patient’s first point of entry into the health care system.
  • A primary care practice is the continuing access point for all needed health care services

I decided to start here because I don’t know that my bosses have ever thought of primary care as other than another service line.

I plan to emphasize the second bullet point. We, like many other Academic Health Centers, have not taken the role of the primary care doctor in “entry into the health center” seriously. That has resulted in under-utilization of some of our specialty services and when I have conversations about care delivery they tend to go along these lines:

Surgeon: Why don’t you send me more patients.

Me: Only so many people need their gallbladders out.

Surgeon: You need to work harder.

I plan to spend the bulk of my time, though. not on where we’ve been but on where we are going.

My plan is to make the following points and let the discussion ensue:

  • Although the Affordable Care Act (Obamacare to some in the audience) will increase the number of “covered lives” through the exchanges, increased Medicaid coverage, and allowing parents to keep their children on their insurance policy, there will be less money in health care in aggregate. There is no way we can justify spending over 17% of the gross domestic product on health care, especially given the outcomes the system produces.
  • The Affordable Care Act has made system based approaches workable. Accountable Care Organizations and other forms of shared savings are being developed thanks to changes in CMS and in particular the Center for Medicare and Medicaid Innovation
  • Good primary care decreases costs and improves care.  The way that primary care doctors are going to be paid is going to be different, though. We are not going to be paid on fee-for-service but instead on managing chronic illness and keeping people out of the hospital.

Decreasing costs is not necessarily a good thing for an Academic Health Center. AHCs tend to rely on high margin services to offset training costs.It may be that we decide not to invest in primary care, relying instead on traditional appeals to “local medical doctors” and developing high margin profit lines. If we elect to develop primary care, it will need to be with an eye to improving care, increasing quality and improving safety. I hope we don’t do it with an eye to putting patients into my specialty colleagues’ exam rooms.

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