I have been in discussions with our college of medicine leadership regarding the future of primary care. The investment of the federal government in Federally Qualified Health Centers and the National Health Service Corps makes it possible for the underserved to have primary care access. I have been recently asked to speculate on the role of primary care for insured patients. BC/BS of Alabama, the insurance that covers 96% of insured Alabamians sells open access to all specialties. My specialty colleagues, as in other medical schools,  have a system that is often difficult for patients to maneuver in but are dependent on ever increasing clinical volumes. They are convinced that increasing the number of primary care physicians might solve some of their problems…Feed the Beast, as it were (video here).
I counsel different. For those of us in organizations not yet in the primary care business at a level that we can take risk, building a lot of primary care will be an expensive proposition of questionable value. I point out that as the exchanges come on board in 2014, there will be a lot of working poor with high deductible plan who will want value. In addition, there are good reasons to offer quality care to the groups of people with a common employer, should they desire.  Employers are worried about health costs and are also interested in other value based outcomes such as increased availability to work, predictability in health care spend, and improved senior employee satisfaction with health benefit. I say we focus on value.
take the example of Intel. The chip company headquartered in the west with 3500 employees,  found that 10 percent of its employees or their dependents are responsible for 70 percent of its health care costs and so just primary care transformation was insufficient. They have instituted a narrow network model.
The model promotes system-wide efficiency via payment reform, accountability, continuous process improvement and waste reduction,” Intel’s report said. “Value-based compensation is based on a global per-member per month target with shared risks and rewards if the results fall outside a buffer zone of expected results.”
They are hopeful that “a treatment cost navigator calculator will make costs transparent and support members in finding high-quality, cost-effective care.” They are offering incentives to make it so. I think we need to pay close attention to these trends. Though primary care is not the answer, cost effective care almost certainly will be.
If we are inefficient, allthe primary care in the world will not capture these patients. What we in academic medicine need to do is, for those clinical areas where we want to compete with our community colleagures, we need to get really efficient. As I tell my colleagues, the beast may need to go on a diet
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