First Step in Reform: Primary Care

The heart of a successful reform effort under the Affordable Care Act will be the creation and implementation of the patient-centered medical home model of care, according to testimony at an Assembly Committee on Health hearing in the Capitol Tuesday.

“We need to look at better management of chronic conditions,” said Assembly member Richard Pan (D-Sacramento), chair of the Committee on Health. “It’s one of the greatest cost factors in our health care system.”

How much cost?

The numbers are “astounding,” according to Sophia Chang, director of the Better Chronic Disease Care Program at the California HealthCare Foundation and one of the panelists at yesterday’s hearing. CHCF publishes California Healthline.

“We’re dealing with an epidemic,” Chang said. “Growing numbers, growing costs.”

She cited several examples, including:

• About 80% of the state’s and the nation’s health care expenditures are being spent on 20% of the population;
• About 5% of heallth care consumers account for 50% of expenditures; and 
• The estimate for the cost of chronic conditions in 2010 hit $635 billion nationally.

“This is no chump change. So we need to think about how to spend those dollars more effectively and spread them across more lives,” Chang said. “So there’s a huge opportunity to zero in on high-cost patients, and lower their expenditures.”

Two of the biggest cost drivers in medicine, she said, are hospital care (particularly readmission to hospitals) and overuse of emergency departments. Chronic care patients — people with diabetes, asthma, heart conditions — tend to use those more-expensive services when their chronic conditions aren’t properly managed, Chang said.

“The bet is, if you establish the patient-centered medical home, you’re going to avoid hospitalization [and ED overuse],” she said.

The answer to these challenges is focusing on beefing up primary care, according to Kevin Grumbach, chair of family and community medicine at UC-San Francisco.

“All this talk about chronic care and the patient-centered medical home is fundamentally about the primary care foundation of a well-functioning health care [system],” Grumbach said. “Systems that are built on a solid foundation of primary care are much better able to deliver the triple aim of better care, better outcomes and lower cost, and in an equitable way.”

Unfortunately, he said, California’s primary care system “is completely topsy turvy,” he said.

“You’re never going to tackle the chronic care challenges in California unless you’re focusing fundamentally on what’s happening in primary care, because that’s where the action is and where outcomes are improving,” Grumbach said. “But our foundation for it is crumbling. We have half as many medical school graduates today going into family medicine and adult primary care medicine and geriatrics as happened 15 years ago.”

Grumbach said he preferred the term “high-performing primary care” or “enhanced primary care” to describe the patient-centered medical home, but whatever you call it, he said, it’s essential to launch some kind of team-based primary care.

“Patients need to know [members of] their care team, first of all,” Grumbach said. “They need enhanced patient access, because if you need a service, you should be able to get it. You need your care coordinated,” he said, between all members of the care team, including in-home support workers, for instance — all of the providers of care and services. “And the final thing is, you need a different payment model,” he said, so that providers are financially rewarded for spending time contacting the palliative care team or the pharmacist, for examples.

“This works,” Grumbach said. “It’s not an abstract notion. In study after study, pilot after pilot, it consistently shows better outcomes. It’s working in a broad range of settings. Quality is better. Access is better. Patient experience is better.”

At the same time, costs go down, he said, because you save money from fewer trips to the emergency department for an asthma attack, for example.

“You pay more for [enhanced] primary care,” Grumbach said, “but you more than make up that cost in reductions elsewhere because of it.”