Enhancing value: Realizing the promise of primary care through effective implementation

Arlene Bierman is the Director of Center for Evidence and Practice Improvement (CEPI) at the United States Agency for Healthcare Research and Quality (AHRQ)

Rick Glazier is a Family Physician and Senior Scientist and Program Lead of Primary Care and Population Health at the Institute for Clinical Evaluative Sciences (ICES) in Toronto, Canada

 

Primary care is foundational to optimizing individual and population health. Health systems based upon primary care provide better access to care while improving health equity and outcomes and reducing costs. Effective models of primary care can greatly enhance the value of increasingly constrained health care spending. Despite large investments on primary care transformation in the US and Canada, primary care has yet to achieve its full promise in either country. Sharing successes and failures from attempts at innovation on both sides of the border can help each country accelerate improvement.

Despite very different health systems, primary care practices in both countries encounter remarkably similar challenges in delivering care. At the point of care, patients’ needs are similar and their experiences too often suboptimal. Primary care clinicians encounter similar barriers to improving patient experience, quality, and outcomes and feel increasingly burdened. Payment models for primary care in both countries create barriers to optimal primary care. Successful innovations are rarely scaled and failed interventions often repeated.

Our binational planning committee for the March 2-3 meeting in Washington DC, “Advancing the Science of Transformation in Integrated Primary Care: Informing Policy Options for Scaling-up Innovation,identified three critical areas in which innovation and learning is happening in the U.S. and Canada that should be shared across borders: 1) managing complex patients with multimorbidity; 2) developing and testing alternative payment models that support needed changes; and 3) addressing disparities in quality and outcomes of care.

  1. Managing Multimorbidity: Although health conditions are often considered in isolation in research and in evidence-based guidelines, it is more common in health care to encounter people with multimorbidity, many of whom have complex health needs. People with multimorbidity depend on primary care to manage and coordinate their care. Primary care practitioners need to develop dynamic care plans in partnership with patients that reflect their needs, priorities, goals and preferences while collaborating with specialists, coordinating care, and managing care transitions. What is the current evidence for effectively managing complex patients in primary care? How can we scale effective models?
  2. Alternative Payment Models: Traditional fee for service primary care payments don’t reimburse for the essential tasks of primary care including support from interdisciplinary teams, care coordination, self-management support, and ongoing communication. At the same time capitated models can create the unintended consequence of incentivizing risk selection. Both payment models present different barriers to optimizing primary care. Rising costs results in the need to enhance the value of health care spending. How can we most effectively organize and finance primary care? What is the evidence for different models of primary care payment? How can we develop, implement, evaluate, and scale innovative payment models that align with patient and health system priorities?
  3. Reducing Disparities: In both the US and Canada disparities in health and health care associated with race/ethnicity, socioeconomic position, gender, and geography are well documented. Primary care has an important role in addressing and reducing these disparities. What is the evidence for different approaches for effectively addressing disparities within primary care? How can primary care partner with other sectors to achieve this goal? How can we develop, implement, evaluate, and scale innovative models of care that foster health equity?

Emerging evidence and methods from both sides of the border can inform direction and options for moving forward. Our goal is to develop a binational research agenda to accelerate innovation, develop evidence and build health systems that deliver high quality, affordable, equitable, efficient care that improves health, respects patient values and preferences, and reduces burden on patients and clinicians. We begin with three central and shared challenges, but there are many more. We hope this meeting is a beginning for fruitful collaboration and learning across borders.

Join the discussion at this invitational Symposium on March 2-3 at #CrossBorderPC2017.  Submit  your work on implementing improvements in primary care to a special theme issue of the Journal of the American Board of Family Medicine  Primary Care Implementation Science.  The call for papers is out. Papers and other products from the meeting will be designed to spark ongoing exchange and collaboration.

 

Disclaimer:  The views in this manuscript represent the authors and not necessarily the policy or views of the Agency for Health Care Research and Quality or the US Department of Health and Human Services.

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