Primary Care in Peril

A recent study published in JAMA looked at the relationship between primary care physician supply and population mortality in the United States. The study covered the 2005-2015 time period.
The authors of the study found that 10 additional primary care physicians per 100,000 population, was associated with decreases in cardiovascular disease mortality, cancer and respiratory mortality by 0.9% to 1.4%. These findings were further validation of the seminal work done by Dr. Barbara Starfield and her colleagues in the past. That’s the good news!
However, in the same time period from 2000 to 2015, the density of primary care clinicians throughout the US decreased from 46.6 to 41.4 per 100,000 population. And even more concerning for Texas, the primary care supply declined more in rural than in urban areas on average.
Why the shortage of primary care clinicians? Here are a few major reasons:

Another factor in the equation of primary care is chronic maldistribution of physicians across the state. As an example, the state’s five most populous counties (Harris, Dallas, Tarrant, Bexar and Travis) have 57% of the Texas physician workforce but only 44% of the total Texas population. Further, in those same five counties, 72% of the physicians are specialists and 28% are primary care physicians. A 2013 study by Parkland Hospital and the Dallas County Health Department highlighted that the ratio of physician-population varies dramatically within Dallas County with a high ratio of 252/100,000 in the Stemmons Corridor to 5/100,000 in the southern sector Wilmer-Hutchins/Seagoville area. The study supports the observation that there is frequently a preponderance of physicians in more affluent areas and fewer in less affluent areas.

Texas ranks  47/50 in the US for primary care physicians per 100,000 population. 33 of 254 Texas counties have no physician at all. And, the closure of rural hospitals adds to the urgency of the need for better distribution of physicians.
There are some bright spots in this story. The 85th Texas legislature granted generous funding for Graduate Medical Education Expansion programs in Texas through which health science centers, medical schools, hospitals and foundations received awards for 63 residency programs. A total of 1,265 residency positions will be supported. Many of the awardees are in rural communities.
The Texas Academy of Family Physicians, Texas Chapter of the American College of Physicians and the Texas Pediatric Society have operated medical student preceptorship programs for more than 10 years. Through funding from the Texas legislature, these programs have paired hundreds of medical students who spend 2-4 weeks with practicing primary care physicians across Texas. There is good evidence that this early exposure to primary care increases the likelihood that the student will pursue a career in primary care. The Texas Medical Association has championed the Physician Loan Repayment program through which physicians in certain specialties (primary care and mental health) who choose to practice in Health Professional Shortage Areas for at least four years receive significant loan repayment funding. Similar programs exist for nurses.
Texas A&M’s ARCHI (Rural and Community Health Institute) recently received a generous grant from Blue Cross Blue Shield of Texas to reimagine rural healthcare in Texas.
How can we more equitably distribute primary care throughout our vast state? There are a several innovative ways including telemedicine and the use of ECHO technology.  A number of organizations are piloting virtual specialist consults to make accessing specialty care easier, especially for rural practices. Community healthcare workers are a vital part of the healthcare team and are being utilized increasingly.
While the aforementioned remedies are ramping up and moving to scale, I believe that we should invest our time and energies into forming high functioning teams in our practices. Effective and efficient teams have great potential to address some of the most vexing problems we are facing. A recent study showed that with well-trained teams, physicians and other clinicians may experience less burnout.

We are honored to have such a team from Bellin Healthcare in Wisconsin participate in the upcoming annual summit of the Texas Primary Care Consortium. Dr. Jim Jerzak, family physician and originator of Bellins’ team based model and Kathy Kerscher, his administrative counterpart will share their experiences and guidance with the Summit attendees. You can read more about Dr. Jerzak and Bellin Health here.

It has been said that necessity is the mother of invention. In Texas, there are practices and systems innovating every day to improve access to primary care. We’ll feature a number of these at the 2019 Summit. So please join us June 20-21 at the Renaissance at the Arboretum in Austin. You’ll be glad you did! For more information, please visit: www.TXPrimaryCareConsortium.org

Won’t you be my (medical) neighbor?

Over the past year, the findings of three large demonstrations of the Patient-Centered Medical Home (PCMH) model have been published. It is fair to state that the studies report conflicting results. Kip Sullivan, a Minnesota-based health policy expert brought this topic to the forefront in his blog post on June 7 of this year entitled “The verdict is in. All three of CMS’ medical home demonstrations have failed.”  But, a recent Health Affairs blog post by Paul Cotton entitled “Patient-centered medical home evidence increases with time” begins with one of Mark Twain’s most famous quotes: “The reports of my death are greatly exaggerated”.

So where does the truth lie? I hope to help shine some light on these findings in this post by presenting results of important demonstration projects and offering suggestions for next steps.
The Federally Qualified Health Center - Advanced Primary Care Project Demonstration was hampered by lack of a multi-payer design, limited financial assistance and short duration. In addition, strengthening primary care for vulnerable and underserved patients is likely to be more challenging than in other settings. Also, the endpoint of this demonstration was achievement of Level 3 NCQA recognition as a medical home. This is but one milestone on the journey to true “medical homeness” and is by no means a stopping point.
The Multipayer Advanced Primary Care Demonstration spanned 8 states and enrolled 800 practices. The quality data was inconsistent but overall the demonstration was budget neutral. Participating practices reported ongoing challenges with health information technology and data sharing as well as lack of alignment across payers. Positive findings included effective leadership, high levels of staff support, and cohesive change teams correlated with better outcomes.
The Comprehensive Primary Care (CPC) Initiative did show that quality was slightly improved, patient satisfaction was stable and provider satisfaction was improved while transitioning from fee for service to a value based payment model. CPC did not require external vetting of practices but relied on their attestation that they were fulfilling the requirements of the project. CPC+ will build on this model and recognize that all practices enter the transformation process from different points along a continuum.

Moreover, a September 10th blog post by Paul Cotton in Health Affairs makes a compelling case for why patient-centered medical homes work. https://bit.ly/2NEDP3j Citing multiple journal articles and published evaluations, Cotton concludes that PCMH recognition by NCQA is associated with better clinical and cost performance. As an example, Cotton cites recently published findings in the American Journal of Managed Care that NCQA PCMHs saved Medicaid $214.10 per month for HIV patients with diabetes, chronic lung disease, asthma, congestive heart failure or behavioral disorders. The savings came from inpatient care and outpatient substance use treatment reductions.

Additionally, a recent report by the Patient-Centered Primary Care Collaborative on the relationship between accountable care organizations (ACOs) and medical homes showed that ACOs with more NCQA PCMHs had greater average savings than those with fewer or zero PCMHs. https://bit.ly/1K2Gw8d

For the sake of completeness, there are several other recognition programs including those offered by the Joint Commission and URAC. I look forward to seeing their data about the impact of their programs.

What elements are necessary for success in a medical home?
This is not an all-inclusive list but captures some of the most important factors:

I have spoken with several thought leaders in the primary care and medical home fields in the last few months about these results and their significance for the future.
A common response was that primary care – no matter how well organized and run it is – can only indirectly affect the cost of care, utilization and outcomes.  Once a patient leaves the primary care office, our ability to influence what happens next is limited. In other words, the patient-centered medical home primary care model is necessary but not sufficient. What is sorely needed is system transformation starting with the primary care and extending throughout and beyond the complex health care system.
In 2010, the American College of Physicians published a position paper called “The PCMH Neighbor: The Interface of the PCMH with Specialty and Subspecialty Practices”.
https://www.acponline.org/system/files/documents/advocacy/current_policy_papers/assets/pcmh_neighbors.pdf.It offered a framework to categorize interactions between practices and put forth a set of principles for care coordination and addressed the importance of incentives for specialty practices. The paper offers standardized referral forms for improved bidirectional communication between primary care and specialist practices including the reason for referral (clinical question), social/medical history, medications, what testing has already been done and what is being asked of the specialist – a procedure; a consultation or co-management of the patient as examples.  
The NCQA has a recognition program called the Patient Centered Specialty Practice which recognizes specialty practices that help coordinate and deliver high quality patient-centered care. This program is designed to complement the PCMH program and to expand its reach. The goal is to encourage excellent care coordination by specialty practices leading to less duplication of procedures and fewer hospitalizations. Participating practices include cardiology, dermatology, obstetrics and gynecology, neurology, urology, orthopedics and oncology among others. Although the PCSP program was created in 2013, uptake by payers has been somewhat slow, not dissimilar to uptake of the PCMH in its early days. The PCSP program has great potential to further strengthen the medical neighborhood.
It is clear that the still-prevalent fee for service payment model does not lend itself to widespread acceptance of the medical neighbor model as envisioned by the ACP. But since 2010, there has been proliferation of telemedicine and virtual visits with specialists including e-consults. One of the pioneers of e-consults is the University of California at San Francisco. These consults provide guidance to primary care physicians across the spectrum of patient care. UCSF reports that PCPs implement specialists’ recommendations in the large majority of cases and few patients subsequently require in-person specialty care related to the reason for the e-consult.
We are already planning the 7th statewide summit on primary care and the health home. The Summit will have a new name: Advancing High Performing Primary Care. And the collaboration between the Texas Health Institute and Texas Medical Home Initiative has a new name as well: The Texas Primary Care Consortium. The 2019 Summit (date and place TBD but likely in June) will focus on system level change, the use of technology in primary care and many other timely topics. Be on the lookout for a save the date email soon.
In closing, let’s celebrate the successes of the patient-centered medical home model of care. Going forward, we need to think big and engage the other members of the complex healthcare universe in which we live and work. The move to value based payment will likely help accelerate this movement by aligning incentives more than ever before. In the meantime, won’t you be my (medical) neighbor?

Does a Medical Home Still Truly Exist???

Click here to see Sue's response in the Texas Medical Association Blog featured 4/04/18

What’s up with the medical home in Texas – Part 2

In last month’s blog post I shared information about the number of recognized patient-centered medical homes in Texas. I also mentioned that in Texas, the overwhelming majority of the medical homes are sponsored/owned by health systems.

Since then, I have learned that the percentage of physicians practicing in medical homes in Texas is not dissimilar to the national rate of about 20%. What is perhaps more interesting than that is the according to the Patient-Centered Primary Care Collaborative, roughly 43% of family physicians in the US are practicing in medical homes. I do not have statistics for internists and pediatricians but one can infer that their percentages are significantly smaller.

One of the original Joint Principles of the Patient-Centered Medical Home is that “practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.”

At least 4 organizations have programs that certify or recognize practices as patient-centered medical homes. The National Center for Quality Assurance (NCQA) was the first of these organizations to offer a recognition program in 2008. They have now revised and updated their standards 3 times. They have the largest share of the market with 59,278 clinicians working in 12,724 practices nationwide. There are now over 800 NCQA recognized PCMH practices in Texas.

The Joint Commission’s program, Ambulatory Care Accreditation, has accredited 1,418 sites nationally with 66 accredited sites in Texas. Of these, the overwhelming majority of practices are either Federally Qualified Health Centers or community health clinics. Only one private practice – Southeast Texas Medical Associates in the Beaumont area – is accredited by JCAHO.

Data for URAC and AAAHC, the other certifying organizations are not available on their public websites.

As promised, I am sharing information about the location and ownership of NCQA recognized practices in Texas (map courtesy of the NCQA):

The distribution of medical homes in Texas is fairly consistent with what is known about physician supply and distribution:

With regard to ownership of practices, in 2015 between 45 and 49% of all Texas physicians were individual practice owners compared to 30% nationwide. The number of private practices has continued to decrease in the last several years while there has been massive consolidation of markets in many Texas cities.

This graph shows the distribution of NCQA recognized medical homes by ownership in Texas:

Further analysis of the NCQA data shows that 11 Texas health systems own/sponsor 10 or more medical home practices.

Questions to consider:

1. Why are health systems disproportionately represented among NCQA recognized practices?

In part, it’s because becoming a recognized PCMH is costly in terms of personnel and resources so larger entities have an advantage. Also, larger systems are more likely to be in a position to leverage their PCMH status to gain more favorable insurance contracts that pay them for services like care coordination. Unfortunately, smaller practices rarely have the same leverage.

2. Why would a private practice embark on the journey of becoming a PCMH complete with recognition?

Funny you should ask.I am about to send a questionnaire to private practices that are recognized by NCQA to find out the answer to that question. Stay tuned! And if you get a request to complete the survey, please do! It will add greatly to our understanding.

3. The Joint Principles notwithstanding, can a practice become a medical home without being officially “deemed” as such by an outside organization?

I have no doubt that the answer to this is yes. However, I also believe that a PCMH needs to have a range of capabilities and processes that help it to deliver accessible patient-centered care. Proving this is accomplished through data. Bigger systems typically have more robust data gathering and reporting abilities.

4. And finally, and perhaps most importantly, how can practice culture be measured in a standardized format?

Practice culture that embraces teamwork; acknowledges the contributions of all team members; has strong clinical and administrative leadership ; a unified vision of what is means to be a PCMH and works tirelessly to continuously improve the delivery of care can’t be measured on a form. And only through true cultural change can the promise of the PCMH be fulfilled.

I invite your comments and thoughts.

Till next time.

What's up with the medical home in Texas?

This is the second in a series of blog posts about the state of primary care and the medical home with an emphasis on Texas.

2017 marks the 10th anniversary of the adoption of the Joint Principles of the Patient- Centered Medical Home which serve as the blueprint for transforming practices to this model of care. In my first blog post I shared an overview of the most recent review of research on the PCMH published by the Patient Centered Primary Care Collaborative. The authors conclude that the overall impact of the PCMH has been positive, but not uniformly so. An updated version of the Joint Principles, the 2017 Shared Principles of Primary Care will be released by the PCPCC in October.

People frequently ask me about the state of the Patient-Centered Medical Home in Texas. I can cite statistics on the number of clinicians and practices recognized as medical homes by the NCQA and the Joint Commission and refer people to the interactive location map on the NCQA website. Beyond that, until now, I haven’t been able to shed much light on the medical home in Texas.

In order to learn more, I have embarked on a deep dive into the data on the NCQA website. I will be sharing what I’ve learned in the next couple of blog posts. For now, though, here are some statistics that can help us understand the state of the PCMH in Texas and set the stage for further discussion:

While we don’t have readily available data on rates of PCMH uptake in other states, I suspect that Texas is on the low end of adoption. The next question is why. Although there are a number of reasons, the most compelling one is that transformation to a medical home requires time, leadership, commitment and financial support. It is my strong belief that Texas physicians and practices possess the first three. There has not been widespread financial commitment to transformation in our state.

We know that in states such as Rhode Island, Pennsylvania and Colorado multi-payer initiatives have overall been successful and have accelerated transformation efforts on a larger scale. While there are anti-trust concerns when convening meetings of payers, these can be addressed and dealt with when payers are convened by a governmental entity. My biggest disappointment in the 8 years of working on adoption of the PCMH in Texas is that we haven’t been able to engage the people that pay for healthcare in a meaningful way on a large scale.

I am, however, an eternal optimist. And I want to share 2 stories about practices that have embarked on the journey of transformation. They are inspiring and encouraging.

I recently visited the campus of El Buen Samaritano in Austin. I was directed to “El Buen” by 2 of my colleagues – Tom Manley, CEO of the Texas Medical Foundation and Dr. Dan Crowe, Senior Medical Director for Superior Health Plan. I met Iliana Gilman, the dynamic CEO of that organization. El Buen is a healthcare organization that improves the health and quality of life for Latino families. They were recently recognized as a Level 3 PCMH by NCQA. El Buen is more than a health clinic. Indeed, they sponsor a food pantry, adult education (in English and Spanish), behavioral health services and more. The overwhelming majority of their clients are at less than 100% of the poverty level. When I asked Ms. Gilman why El Buen undertook this challenge, she stated simply that the PCMH offers a structure and framework to put progress in place and to integrate the various services offered there.  I left El Buen with a big smile on my face and a renewed sense of hope in my heart. Felicitaciones!

The second story comes from our devoted friend and colleague Jettie Eddleman. Jettie shared the exciting news that the Texas A&M Family Medicine Residency/TAMU Physicians recently achieved recognition as a medical home by the NCQA. One of the members of this practice is Nancy Dickey, MD, the former President of the AMA and champion for primary care. According to Jettie, the desire to become recognized as a PCMH in a rural Texas practice is secondary to the true desire to do more and do it more effectively in delivering patient and family-centered care. The clinic is in Bryan, Texas, an underserved area. Jettie notes that the transformation was facilitated through the A&M Regional Extension Center and was made possible, in part, through funding from the 2011 Texas Medicaid 1115 waiver. In Texas, we say “Whoop”! Well done, Aggies.

People ask why a practice decides to become a medical home. These 2 stories underline the fact that many practices undertake this journey because it is the right thing to do for their patients, clinicians and community.

My next blog post will present data on ownership, specialty (IM, FM, peds or multi) and geographic distribution of PCMHs in Texas. In the meantime, I’d love to hear your thoughts on my posts.