How Might we Structure Primary Care to Offer More Value to Patients?

Published 2020.9.1

In October 2013, Porter and Lee published “The Strategy That Will Fix Health Care”. They defined value as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes. The authors criticize several of healthcare’s narrow solutions that have not increased patient-oriented value, including:

  • Combat physician fraud and self-dealing – this work may impede integrated care across organizational boundaries
  • Consumer-driven healthcare – without more information about costs and outcomes, this work seems to shift more costs to patients without improving value
  • Evidence-based medicine – published evidence only covers a small fraction of the care required for most patients and guidelines are frequently out-of-date as new knowledge continues to be created daily
  • New, more convenient models of primary care – retail clinics do not appear to address the bulk of healthcare costs (The authors would have included telemedicine in this category if telemedicine was a larger phenomenon in the early 2010’s)
  • Global capitation – focus on reducing overall spend without a concurrent focus to increase value
  • Medical error reduction – work on improving safety is important, but does not reorganize the healthcare system to maximize value from the patient’s perspective
  • Care coordination, especially for expensive patients – when operating within a fragmented system, care coordination has not been shown to markedly increase savings (the authors claim 4-7%, but do not provide a reference)
  • Electronic medical records – the technology requires restructuring care delivery and payment to increase value

Porter and Lee were suggesting a fundamental shift in primary care away from managing a wide variety of patients toward integrated practice units (IPUs), a dedicated team of clinical and nonclinical personnel who provide the full cycle of care for the patient’s condition(s). IPUs were expected to manage the disease, its related conditions, complications as well as engage patient and families in care. The authors expected this work to expand the ongoing work of Patient-Centered Medical Homes.

There are a few articles in the peer-reviewed literature that include “integrated practice unit.” The only randomized, controlled trial with integrated practice units I could find included 840 patients in Singapore. The intervention included a multidisciplinary team of integrated care nurses, pharmacists, medical social workers in groups led by attending family physicians who shared a common electronic medical record. The IPU included inpatient and outpatient teams. Before discharge, the nurse care managers combined standardized action plans for chronic diseases (e.g., congestive heart failure, diabetes mellitus, chronic kidney disease) with more personalized plans for other conditions (e.g., mental health conditions) that resulted in an individualized care plan with written discharge instructions, patient appointments, medication changes and contact information for the outpatient nurse case manager. The outpatient care manager followed up with:

  • a phone call with 72 hours of the patient’s hospital discharge to assess the patient’s condition and ensure adherence to the care plans and successful activation of community services,
  • a home assessment within one week of discharge when the case manager assesses the patient’s medical condition and health literacy, competency of the caregiver, availability of nursing and home care equipment, adequacy of social support, safety of the home environment and adherence to medication, and
  • scheduled weekly check-in calls.

Patients were discharged from the program three months after hospital discharge.

The intervention group’s 30-day readmission rate was 0.25 compared to 0.38 for the control group (a 33% reduction). The intervention group’s 90-day readmission rate was 0.67 compared to 0.90 for the control group (a 26% reduction). The intervention also had positive effects on 180-day readmission rate, ED visits and hospital length-of-stay. The intervention saved an average of S$2954 per patient who received the intervention, not including any indirect cost savings.

Intermountain Health embeds clinical pharmacists in primary care medical home practices. The pharmacists co-manage diabetes and hypertension. The pharmacists can initiate, modify and discontinue medication therapy, order laboratory tests, provide education and refer patients to other healthcare professionals. They interact with patients over the phone, via secure electronic messaging and face-to-face. In January 2018, the group published their intervention’s effect compared to a group not exposed to the pharmacy team selected by propensity-score matching. After a priori adjustment for confounders, patients exposed to the pharmacy team were 93% more likely to achieve a BP goal of < 140/90 mmHg (Odds Ratio [OR] = 1.93 [95% CI 1.40, 2.65]), 57% more likely to achieve HbA1c values of < 8% (OR = 1.57; 95% CI = 1.06, 2.34), and 87% more likely to achieve both disease management goals (OR = 1.87; 95% CI = 1.41, 2.50) compared with the reference group. Patients exposed to the pharmacists had more ambulatory encounters with a primary care providers, specialists, and care managers. They also had more emergency room visits (0.27 events/patient-year versus 0.22 events/patient-year, p=0.007) and hospital admissions (0.13 events/patient-year versus 0.11 events/patient-year, p=0.25).

Consistent with Porter and Lee’s focus on increasing a patient’s perception of healthcare value, reorienting primary care might include processes to help patients self-triage, manage chronic conditions remotely and balance competing priorities and preferences to maximize a patient’s quality-of-life. For new symptoms, helping patients understand what factors constitute an emergency, what require an office visit and what might resolve on its own could increase value over what is currently provided by many outpatient clinics. Using virtual check-ins to assess vital signs or patient symptoms remotely to trigger an outpatient visit only when a therapeutic intervention would lead to more meaningful visits rather than scheduling future follow-up visits based on a provider’s intuition. Finally, clarifying a patient’s preferences for treatment efficacy, cost and side effects across multiple conditions is likely to higher value care.

A recent meta-analysis included 27 studies of online symptom checkers or health assessment services for people seeking input about an urgent health problem into a qualitative synthesis. The online tools did not seem to increase risk for patients, but the data were weak. The tools tend to have lower diagnostic accuracy compared to health professionals. The results were inconsistent in regard to clinical and cost-effectiveness outcomes, disposition to the highest-value location (i.e., highest likelihood of making the correct diagnostic or treatment decision at the lowest price) and patient compliance with advice given. Given the range of possible outcomes with non-specific symptoms that may have different implications based on a patient’s demographic, medical history and medication, it may be too soon to expect a technological solution to helping patients determine where best to go. Today, many outpatient practices have a clinician answer after-hours questions. If the clinician can access the electronic medical record, they may be able to provide tailored advice about what might need to occur. Ambulatory clinics might improve this process by exposing patient-specific instructions about what types of symptoms are best managed at nearby healthcare facilities (convenience clinics, urgent care centers and emergency rooms) within their patient portals and sharing that information with members of the healthcare team.

Virtual check-ins, non-face-to-face patient-initiated communications, may help manage patients at a much higher value than face-to-face encounters. Medicare reimburses virtual check-ins at a much lower rate than telemedicine and remote patient monitoring. In value-based arrangements, providers may reduce member spend on physician face-to-face encounters while managing patients’ chronic disease burden with telephone or video interactions and trips to a nearby laboratory at a much lower price point. Other members of the healthcare team like nurses, pharmacists and dieticians could also provide additional contacts for patients outside an office visit. Until we have more clarity about the best use of virtual technology in ambulatory settings for chronic disease, many clinicians might feel most comfortable restricting virtual check-ins to managing chronic disease after a definitive diagnosis that was made face-to-face.

Interestingly, virtual encounters might enable patients to determine their diagnostic or treatment preferences before meeting with a member of the healthcare team to determine what decisions are most consistent with their values or desires. The 15-20-minute face-to-face office appointment template reduces the likelihood that any meaningful preferences are likely to be identified, much less discussed during a traditional office encounter. Virtual check-ins allow healthcare teams to deliver preference assessments to patients and their caregivers before a visit. Team members can assimilate the responses and provide more tailored information about what decisions are most important to the patient within a virtual visit.