Why Quarterbacks and Primary Care Physicians Need an Aligned Team to Succeed

Raise your hand if you have a primary care provider.  No – you are not alone.  Many people, especially those with no chronic health issues are opting not to have a primary.  Instead, when needed, they visit an urgicenter or a clinic in a chain drug store.  This provides them with care for common ailments (think the flu), preventive
care (flu shots) and non-emergent disorders such as sprains and strains.  The reliance on these alternate sites fits in with their life-styles – they want to be seen when they want, not dependent on scheduling an appointment, an extension of today’s immediate gratification existence.

The primary care provider should be the quarterback of your health care team, assessing the situation, determining who might be needed and calling the play to reach the goal line – your continued health.  Along the way, your primary can determine what the most effective treatment is, what tests are needed, if a specialist is in order and whether you need to be hospitalized.  He or she literally controls both the direction and the cost of your care.  One study found that 100 providers control about $1 billion of health care spending.  So there should be a lot of emphasis on primary care providers.

But that is where there seems to be a disconnect as the health care industry tries to realign itself.  Previous generations of primary care providers provided care and direction to their patients in the office as well as at the hospital.  Sure, if it was a teaching hospital, you would probably have residents, interns and medical students in and out of your room but decisions were ultimately made by the attending physician, the person you saw in an office year in and year out.

Now inpatient care is typically managed by providers who are hospital-based only (e.g. hospitalists), and care outside the hospital walls reverts to the primary.  This is supposed to help better manage care, at least in the hospital, however it actually results in a lack of coordination.  Inpatient care centers on the care in the hospital.  What happens outside the walls is not always considered.  This results in fragmented care, increased ED visits and readmissions.  All of which increase the cost of health care.

We are seeing new changes in the delivery of health care – medical homes, accountable care organizations, new entrants into the freestanding medical clinic arena (including Walmart and CVS) and the list goes on.  The key is to encourage the various entities to work together in managing the care of patients in a collaborative fashion to achieve higher quality care, lower costs and safe care.  And the centerpiece must be the primary care provider.  Regardless of the structure chosen, it always comes back to the provider.  So it is vital that a mechanism is chosen that incents all providers to make the right choices.  Gainsharing may be part of the solution – providing an incentive at a time when patient loads, paperwork and more complex patients are consuming more and more of providers’ time, but not increasing their incomes.  A tool that can encourage hospitalists to work hand-in-hand with other specialists and primary care providers is a critical component to care coordination in the inpatient and outpatient setting.

Providers need a reason to change their practices; gainsharing may provide the motivation.  Redesigning care through pathways, making processes flow more efficiently and making information more readily available can be first steps in the process.  Including a gainsharing strategy into an ACO or medical home signals the provider that they are valued and may give them the push they need to change their approach.  But their role as the quarterback will only work if more people get on their team – so go out and find yourself a primary care provider.