Sunday, May 24, 2015

Why Population-Based Care and Disease Management Can Increase Access to Primary Care

If the population health management (PHM) service industry needed just one evidence-based medical journal article to justify its existence, it couldn't do better than this. Writing in the New England Journal of Medicine, Amireh Ghorob and Thomas Bodenheimer advocate for Sharing the Care to Improve Access to Primary Care.

The authors argue there can be only one solution to the twin challenges of dwindling primary care physician (PCP) numbers and the increasing burden of chronic illness : reallocating clinical responsibilities away from PCPs to empowered non-physician team members. These responsibilities include, but are not limited to a) prescription drug monitoring, titration and renewals, b) scheduling and processing of routine blood testing (like cholesterol) and imaging studies (like mammography), and c) counseling patients about lifestyle changes, medication adherence and their preferences, priorities and goals for their chronic conditions.

In order for all this to happen, Mr. Ghorob and Dr. Bodenheimer suggest two ingredients will be necessary: 1) payment reforms that make teaming profitable and 2) physician compromise over their long-cherished notions of control.

That's precisely the approach that has been used by the PHM vendors for decades.

They have nurses, they rely on the teaming, they can manage routine prescriptions, testing and counseling and they can do it for a relatively small monthly fee. They've also learned their lesson: the vendors are doing a much better job of navigating through the doctor-patient relationship and discerning the important differences between clinical responsibility and busy-work control.

A far less important issue is the location or level of service provided by the non-physicians. 

The Disease Management Care Blog argues that sorting that out is a local decision based on physician preferences, pre-existing clinical infrastructure, history and organizational culture. Highly integrated systems may prefer to achieve teaming by transforming their primary care sites into medical homes. Less integrated networks may prefer a shared services model that in or outsources the teams. 

The point is that there is no one-size-fits-all approach to relying on teaming to increase access to primary care. Dr. Bodenheimer has confirmed which are the basic ingredients.  Now it's time for the rest of the system to figure out the details.

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