Is Lean Primary Care the Next Bandwagon?

Bandwagon movements have been very common in primary care. They have been very distracting. The failure of Primary Care Medical Home for many reasons now leads to the need to have another bandwagon. Lean Primary Care may lead the charge to become the next bandwagon.

The rosy reviews have been seen in the usual media sources. These indicate a 5% increase in productivity, guaranteed to attract attention. Whether this was Lean or the movement of physicians into the action is impossible to address - except in the media and in the article.

Which would you read

• Scaling Lean in Primary Care Impacts on System Performance or
• Moving Physicians from Back to Front Offices Improves Performance

Lean Primary Care Meets Many of the Criteria of Primary Care Medical Home

The usual suspects are present such as inflated claims for results despite short term data collection. The problems also persist:

• Lean is too vague - a similar problem with Primary Care Medical Home. There is no way to assess whether these are selective clinics with better patients and cash flow or not. Changes do tend to work for quality and costs in such patients and clinics. Terms such as not for profit mean little. The same is true for safety net.
• Confounders that could explain the results without "Lean" are seen. For example, the physicians were moved from their private offices to work places shared with the medical assistants. The paper could have been titled and written differently because of the location rearrangement instead of "lean." Lean obviously draws more attention but may not explain the findings.
• The study location was vague. A not for profit can be profitable or not as well as in better or worse locations. The entire context of the study is difficult to assess. Primary Care Medical Home and other innovations are more likely to do well with patients already spending too much and with inherently the best outcomes. Generally these practices have the best insurance plans that also pay better - as is also seen in the largest practices. Larger means better contracts and annual escalation clauses. Smaller often means take it or leave it contracts and concentrations of patients with lowest paying plans.
• The primary care physician definition was vague. Those providing even as low as 5% FTE were included. The selection should have been over 50% FTE as primary care physicians. Fragmentation can be pushed, continuity may not be as easily pushed.
• The study combined different primary care types but did not offer a breakdown - IM can be more costly and least efficient, as have certain types of not for profits. Rural family medicine can also have high complexity and more chronic disease. An obvious concern would be whether patients had as many care needs met.

Other problems common to primary care remain: 

• No show and same day were not mentioned. Dealing with these areas alone can change results.
• Nurse practitioners were not mentioned. 
• Physician assistants were not mentioned. 
• The word nurse was mentioned, but it is not certain that RNs were involved as many have been eliminated from primary care over the decades due to cost factors.
• Community was not mentioned
• Changes in patient panels were not mentioned.
• Clinical quality was essentially not measured and should not have been mentioned. A few measures are not reflective of overall quality and should not be represented as same. There are no patient controls for quality.
• Physician satisfaction was also difficult to assess due to short length of the study as noted. It is not clear how readiness for the change was assessed, a possible indication that it may not work other than in early adopters

Flow was pushed - which could be good in some poor productivity settings (Veterans Administration, others) but may not be good in others running on or over the edge.

There will be more studies, and given the current example there should be more questions than answers generated.