Are We Moving Away from Achieving Value in Primary Care?

Achieving Value in Primary Care is an article worth reviewing in the current Annals of FM. It is a theoretical article with substantial review of the existing literature. Unlike many of the popular reports supportive of innovation, this one takes a realistic look.

Headings include:
  • Primary Care Medical Home Recognition May Not be a Valid Indicator of Model Adoption
  • The Existing PCMH Model May Not Result in Substantial Improvement in Outcomes
  • Cost Impact of PCMH is Difficult to Demonstrate
  • Demonstrating Value - The 2 initiatives showing the most substantial impact on quality and on cost or utilization—the Vermont Blueprint for Health and the Comprehensive Primary Care Initiative (CPCI)—provide substantial resource support for PCMH transformation and care delivery.
  • Value Could Be Considered Health, Healing, Cure, Precondition Support, Experience of Care Divided by Cost - internals to patient not externals

Take Homes from Recent Articles About Primary Care and Quality

Quality is about patients, situations, and determinants with perhaps 10 - 20% of the outcome that could be addressed by clinical interventions if the interventions were very specific, efficient, and effective.

If we invest in primary care, we might actually improve cost and quality outcomes - but we are not doing so. The dominant focus remains cost cutting rather than investment in areas that might improve care. It is likely that numerous claims about PCMH and other innovations only distract further from improvement.

Quality focus areas such as PCMH cost $105,000 per physician per year – the opposite of investment in primary care - also from Annals of FM

Additional quality measures cost over 15 billion a year in just 4 specialties or $40,000 a year and 785 hours per physician per year (Casalino current Health Affairs). This is the opposite of investment in primary care, more care, and more care where needed. This appears to be the opposite of value in primary care and of valuing primary care physicians.

Much of what we see in the literature is vague about primary care, cost, and quality, despite numerous claims about quality improvement, cost savings, and “value.”

What we see as “value” in primary care is as yet unsettled, but this has not prevented payment design blowing past research and testing all the way to implementation. This could be considered unethical experimentation on the basis of lack of informed consent, application to vulnerable populations (access reductions and limitations of care where Medicaid and Medicare populations are concentrated), lack of beneficent intent (cost cutting focus, shrinkage of primary care capacity), failure of proper testing, failure of small scale testing to prevent adverse consequences.

What we have is a few people forcing their ideas and innovations upon substantial US populations without regard to their best interest or the best interests of those who attempt to provide care for them. The process is so flawed that this will not even result in the kind of data that can actually improve matters.

Time for Quality in Quality Studies

A Rough Guide to Spotting Bad Science

Pressures Mount for ACA Changes

The Real Kerfuffle - How much chaos can family physicians stand?

IOM Panel Calls for Training in Social Determinants (But Needs Such Training)

Is the IOM Waking Up?

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand

Primary care can be recovered and should be recovered.


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