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Independent study of potential benefits of direct primary care needed

The California HealthCare Foundation has published an issue brief on pre-paid primary care plans, known as direct primary care.  Direct primary care (DPC) unbundles physician office visits and some other limited services from health insurance coverage and is directly paid out of pocket by consumers, leaving insurance to cover hospitalizations and catastrophic care events.  It has the potential to lower premiums since it eliminates the administrative burden on both payers and providers to process routine care reimbursements as well as potentially avoiding higher cost care by allowing primary care providers to offer more intensive preventative care and lifestyle coaching to ward off preventable, chronic conditions.

The issue brief notes some DPC providers have pegged overall health care cost savings in the 20 to 30 percent range.  Cost reductions of that size can go a long way toward achieving the triple aim of better care at lower cost and with better outcomes and warrant independent research to more fully investigate the potential savings.  The research should also examine how DPC might favorably affect the business model of primary care medical practice and its potential to attract more physicians to the field at the same time the number of people with insurance coverage – and the concurrent need for primary care practitioners – is expected to increase starting in 2014 under the Patient Protection and Affordable Care Act.

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Physician-nurse turf battle heats up as nurses earn doctoral degrees

The New York Times today reports on the trend of nurses continuing their educations to obtain doctoral degrees in nursing.  Physicians view the trend as another salvo in a longstanding scope of practice turf battle with nurses and some experts don’t see it doing anything to improve health care in the United States:

“Everyone’s talking about improving patients’ access to care, bending the cost curve and creating team-based care,” said Erin Fraher, an assistant professor of surgery and family medicine at the University of North Carolina School of Medicine. “Where’s the evidence that moving to doctorates in pharmacy, physical therapy and nursing achieves any of these?”

Perhaps not immediately.  It will be interesting, however, to watch the role of nurses as primary caregivers evolve as more Americans gain access to medical coverage as the Patient Protection and Affordable Care Act (PPACA) continues to be phased in over the next several years.   A major concern that there will be too few primary care and family physicians available to serve those who gain access to care under the PPACA.  In response, there could be a major shift in medical care in which nurses become primary care providers with medical doctors serving as surgeons and specialists (as many doctors already do) treating patients with multiple complex and rare medical conditions that exceed the training and expertise of nurses.

Insurer’s medical home initiative achieves cost savings double amount invested

The Associated Press reports a two-year-old initiative by Blue Cross Blue Shield of Michigan that provides patient-centered preventative care based on a “medical home” treatment model is proving to be a good investment, producing savings double the $35 million invested by the insurer in 2010.

The initiative involving 2 million lives embodies a conceptual rethinking of the current “sick care” medical treatment model in which multiple fee-for-service providers treat symptoms and co-morbidities of chronic conditions.  Instead of these patients merely counseled to make lifestyle changes, a multi-disciplinary team coordinated by a primary care physician develops a comprehensive care and prevention program.  Patients are provided a large degree of ongoing guidance and coaching to help them permanently adopt healthier lifestyles and reduce high cost medical care utilization.

The Patient Protection and Affordable Care Act (PPACA) requires the U.S. Department of Health and Human Services (HHS) to develop reporting requirements for health insurers by March 23, 2012 on how patient health outcomes are improved through the use of medical homes as well as more effective case management, care coordination, and chronic disease management.  Last month, HHS launched a 3-year pilot program to test the use of the medical homes for high cost Medicare and Medicaid patients as authorized by the PPACA.

Section 3502 of the PPACA also provides for grants to states, state-designated entities and Native American Tribes to establish community-based interdisciplinary teams to support primary practice-based medical homes.

A critical success factor for the medical home model is boosting the supply of primary care and family physicians.  The current fee-for-service model has created strong financial incentive for physicians to instead pursue lucrative specialty practices.  That means over the long run, moving toward a more preventative, health maintenance-based medical treatment model will require changing the underlying economics of medicine as it’s currently practiced in the United States.

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