Improve Primary Care

Providing "always on" care through same-day appointments and extended hours and ensuring patients have accessed recommended care are just two of the 10 characteristics shared by ideal primary care practices, researchers have found.

Although healthcare costs in the U.S. have increased 10-fold since the 1980s, a new reportidentifies a cluster of primary care practices in the U.S. that provide patients with high-quality care while keeping costs low. The study was released by the Peter G. Peterson Foundation and Stanford University's Clinical Excellence Research Center (CERC).

"The research that we announced proves that high-performance healthcare is not only possible, it already exists in parts of the U.S.," foundation president and chief operating officer Michael Peterson said in a press release. The foundation recently invested $200 million to examine best practices in delivering high-quality care.

If all primary care practices implemented the features of these high-value practices, healthcare spending could drop by as much as $300 billion each year, the researchers estimated.

CERC researchers analyzed health and insurance data to locate practices that best fit the profile of low-cost and high-quality care. Using the Health Effectiveness Data and Information Set (HEDIS), a tool used by U.S. insurers to measure health performance, the researchers isolated the practices that ranked in the top quartile for quality and the bottom 25% for annual health spending.

Less than 5% of the roughly 15,000 primary care practices CERC studied fit that profile. Researchers based their rankings on 41 nationally accepted HEDIS measures and weighted records to account for practices with more seriously ill patients.

Next, researchers visited a sample of the high-performing primary care practices as well as those with average rankings. Blinded to the status of each practice, the researchers observed office behavior and conducted in-depth interviews with physicians and staff at each site; they recorded unique habits that might account for a primary care team's performance level.

"All we asked them to do when they went on site was to discern whether there was anything about how the practice was working that they as experienced physician assessors felt was out of the mainstream, distinctive," said CERC director Arnold Milstein, MD, MPH.

"We didn't go in with presumptions about what we would find. This was pure discovery."

The 11 practices chosen by the CERC team included physician-owned primary care clinics, multispecialty groups, federally qualified health centers, and one hospital-owned-and-operated primary care practice. The facilities were found in major cities as well as small towns in several states, including Arizona, California, Texas, Minnesota, Ohio, Tennessee, Florida, Massachusetts, and New York.

The distinguishing features of the exceptional practices followed three themes: deeper patient relationships, broader interactions with the healthcare system, and a team-based approach to delivering care. About two-thirds of these features overlapped with the patient-centered medical home model and with the American Academy of Family Physicians (AAFP) Choosing Wisely recommendations, Milstein said.

Robert Wergin, MD, president of the AAFP and a primary care physician in Milford, Neb., said he was not surprised by the range of providers he saw listed as positive outliers. "If you can find a practice who has these processes, these traits, these visions, you can get that care anywhere from Boston to Milford, from metropolitan to urban to rural situations."

The other characteristics displayed by high-value practices were:

●Conscientious conservation. Care teams conserve resources without undermining patient health. High-performing practices ensure that patients receive all evidence-based preventive care and treatment, but they also individualize care, giving high-risk patients longer appointments, frequent phone calls, and, in some cases, house calls.

●Treating complaints as gold. Exceptional primary care practices take complaints seriously and consistently solicit patient feedback.

●Responsible in-sourcing. These practices provide as much care within the practice as their training allows. Basic procedures, such as skin biopsies or suturing, are handled in-house whenever possible.

●Staying close. The best physicians and care teams develop personal ties with hospitalists and emergency department physicians. In turn, these external providers keep care teams informed regarding patients' progress and changes to their treatment plans.

One of the most difficult aspects to transforming care is overhauling payment structures. In the fee-for-service model, volume is rewarded over quality, so a physician who sees 40 patients quickly gets paid more than one who sees 20 patients comprehensively. All of these aspects should be taken into consideration in order to improve primary care.n