Health Care Reform: A Time for Innovation

By John Jenrette, MD, Chair of the Board, California Association of Physician Groups
CEO, Sharp Community Medical Group

Health care reform represents a true time for innovation for physician groups and with that comes a world of tremendous opportunity. California medical groups in particular are now perfectly positioned to forward its message about accountable, coordinated health care driven by aligned incentives and efficient, high quality care. It is therefore not surprising that we have advanced the California coordinated care model with the development of the six Pioneer ACOs, two shared-savings ACOs, and numerous commercial ACOs throughout our state. California’s system of delivery is now recognized across the country as leading the way.

In leading the way, two important and substantive processes of care delivery and innovation will see increasing efforts and opportunities for improvement and change:  1) the continued strong focus on managing complex chronic illness, and 2) the need to transform primary care services to complement more accountable delivery systems of care.

The continued focus on managing complex chronic disease is of utmost importance based on the high cost of care for this subset of our population. Whether it is the top 5% of the commercial population that accounts for 60% of costs, or the top 1 to 2% of the Medicare population that accounts for 20 to 25% of costs, the need for innovation in the medical services we provide to the chronically ill is essential. We must continue the current effective programs and further advance new approaches to provide coordinated, accountable care in the correct setting of home and/or community, involving both patient and family. Ultimately, care of these patients must occur outside of the acute hospital setting. To achieve this, we need to educate the public and our physicians on the best delivery of end-of-life care and services. When we counsel these patients, we need to be comfortable with the dialogue. As physicians we must counter inflammatory rhetoric, such as the language of  “death panels,” to focus on meeting the expectations and desires of our patients in their time of need.

The second urgency for physician groups and health care reform is the transformation of primary care. Primary care is the foundation of medicine, but it must evolve to remain vibrant.  Health care delivery systems around the world that have primary care as their backbone are shown to deliver higher quality medical care at the lowest cost.

The problem we face here in America, however, is the erosion of the primary care foundation. A large portion of the primary-care workforce is now approaching retirement age, and current medical school graduates are choosing specialty practice, which is higher paying and offers greater life balance. Residency graduates entering adult primary care have dwindled to less than half of the rate of 12 years ago, and this trend seems to be getting worse.

The erosion of the primary care workforce is further driven by the changes and demands of health care reform, including: greater access challenges for patients to primary-care services; additional paperwork (or EHR requirements) in primary-care offices; keeping up with medical advances; increasing demands to provide wellness services; management of chronic disease; and the need to address important social determinants of health. These demands and the attendant increased workload should have us all concerned about the future of primary care.

So, how can we support primary care going forward? What are our plans to replace our aging workforce and to reinvent ourselves for the future? What innovations are needed to create success for all of us?

Ultimately, we need sustainable solutions. We must work collectively to advance primary care. We need primaries to be working at the “top of their licenses” and to engage their office support teams to help deliver outstanding care for patients. We must also provide the tools and technology that advance and streamline these changes and allow for greater focus on populations and gaps in care that lead to poor outcomes.

If we focus our energy and are successful in our efforts, what would primary care look like? I envision success in the rejuvenation of primary care as a preferred career path for the majority of medical school graduates. Our success would return joy and fulfillment to the practice of primary care medicine and remove the scut work from physicians’ desks. It would also rectify and right-size compensation for primary-care services, recognizing and rewarding the real value of a strong healthcare delivery system with its foundation in primary care.

The California Association of Physician Groups will be undertaking many initiatives to address the advancement of primary care over the next few.  I hope that other physician groups and associations across our nation will join us in this effort.

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