QUALITY: There's No Place Like (a Medical) Home

What if we told you a program in North Carolina reduced Medicaid spending in one year by close to $244 million while improving care? The N.C. program offered primary care doctors a $3 per-patient, per-month payment to manage the patients on top of the usual fees for clinic visits. It also organized a multi-disciplinary team of medical personnel to assist the patients. The result: doctors spent more time with patients, coordinating treatment for chronic conditions and reducing hospitalizations. The overall quality of care improved.

The Patient-Centered Primary Care Collaborative (PCPCC)-a broad coalition of business leaders, policymakers, primary care physicians, and other stakeholders is looking carefully at success stories like North Carolina's to see how our whole health care system can redevelop our primary care infrastructure to control costs and improve quality in our country. After all, there's a reason it's called primary care.

Primary care matters. Just take a look at MedPAC, the WSJ's Health Blog, the NEJM or my forthcoming book, Flatlined—you'll see an airtight case for expanding primary care and changing how we pay for it and provide it. At the PCPCC's annual stakeholders meeting Wednesday, I was encouraged to see how such how changes are being translated into reality through the paradigm of "medical homes." These "homes" are the locus of patient-centered, accountable, primary care delivered in one place by one doctor or group of doctors assisted by a multi-disciplinary team. This model is being tested in both public and private sector initiatives across the country. (See the PCPCC''s recent guide for purchasers here).

This energized meeting was packed with individuals and institutions committed to seeing real change in primary care. It was only fitting then, that my colleague Len Nichols, Ph.D., gave the keynote address. Len placed the concept of the medical home within the broader framework of national health reform. He emphasized the potential for medical homes to realign the incentives of our health care system toward a model of "shared savings." Physicians would be paid for the quality—not just the quantity—of care they deliver.

We get what we pay for in health care, and right now we're not paying primary care doctors to act as stewards of their patient's health. In fact, the typical Medicare patient has multiple specialists and even more than one primary care doctor most of whom do not know what the others are doing. Yet, in many areas of the country, primary care doctors are taking no new Medicare patients because they are paid so poorly and their role in managing care is so devalued. The result is poorly coordinated medical care of variable and often mediocre quality. The doctors who are trapped in this bad system do not like it any more than the patients. It is a case of good people working in a bad system, and it can't be changed fast enough.

Experiences like the state of North Carolina have shown that investing in primary care can improve quality AND reduce costs. Coalitions like the PCPCC are trying to determine the details of how primary care doctors should be paid and supported in managing patients. The task ahead is to create a sustainable model so that primary care becomes the backbone of U.S. medical care. It will be like the old days when most people had a trusted doctor to guide them through the medical system, to manage their chronic conditions without hospitalization where possible, and to provide preventive care so that they did not develop illnesses. I believe that this dream is on the way to becoming a reality.