Complex Conditions, Team Based Care: Primary Care's Next Potential Phase

If health care had a definitive "face," the primary care physician would likely occupy the position. The primary care physician is often a patient's first contact with recovery and in turn, plays a crucial role in public health care: making the initial diagnosis.


Primary care physicians see a staggering variety of patients and conditions on a day to day basis. Many of these conditions are treatable within one office visit, but occasionally they're more severe. When patient conditions are determined to be more complicated, or specialized, primary care physicians can refer them to specialists, who can address these patients in a more specific manner, drawing on their own experience of a given school of medicine. Patients then convene with specialists regularly to monitor their condition and develop a treatment plan.

This is the traditional (and highly paraphrased) pattern for how most patient diagnoses work. However, recent data from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care indicates that this paradigm is rapidly shifting, and that more and more patients, particularly those with complicated and chronic health conditions, are seeking the advice and care of their primary care doctors than they are with specialists and sub-specialists. The development becomes increasingly more interesting when examined in the current health care climate that seems constantly faced with threats of imminent physician deficits, and statistics the number of medical students entering primary care in flux.

Just How Much?

A summary of the aforementioned research, published in the January-February issue of the Journal of the American Board of Family Medicine illustrates these shifts. Led by Manisha Sharma, MD, a visiting scholar at the Graham Center, and a research team, the study (entitled "Patients with High Cost Chronic Conditions Rely Heavily on Primary Care physicians") examined outpatient physician in an effort to determine the frequency of primary care visits versus specialist visits. Their data was culled from 2008 National Ambulatory Medical Care Survey for care, provided for each of the 14 high-cost chronic conditions listed in the Centers for Medicare and Medicaid Services Chronic Conditions Dashboard.

Their research indicates that 86 percent of asthma visits occurred in the primary care physician offices, verses 14 percent which occurred in sub-specialist offices, as well as 84 percent of visits for chronic obstructive pulmonary disease which occurred in primary care physician offices, versus 15 percent in sub-specialist offices. Both conditions represent a substantial portion of health conditions that all physicians must treat, with CDC and American Lung Association figures attributing $56 billion in medical costs for the former and $49.9 billion for the latter.

"These data demonstrate how much patients depend on primary care physician to take care of these complex and chronic conditions," says Andrew Bazemore, MD, MPH, director of the Graham Center. "Many of these patients have multiple chronic conditions, so a physician with expertise in the whole person and the broad range of medical diagnoses is instrumental to ensuring that all their health needs are met."

This data has led some team members to push for a semantic distinction for those in "primary care" suggesting that the name "Primary Care Physician" fails to account for the entirety of their position. Since an increasing amount of the country's health burden continually falls on these physicians, some suggest that the name "complex care physicians" is more accurate.

What's in a Name?

But why bother with this kind of distinction? Does it truly matter? In terms of public health, it doesn't, but the suggestion does indicate a changing landscape for primary care medicine generally. Essentially, the data suggests that the role and influence of, as well as the dependence on, primary care physicians has been expanding, and it may be time for other members of the health care equation to shift as well.

Chronic health conditions are defined as those which result in long-lasting effects. Generally speaking, diseases become "chronic" when their effects last for longer than three months. After a diagnosis from a primary care physician, patients with chronic conditions often learn about the necessary lifestyle decisions and habits they must make, to properly deal with the condition. The subsequent result (and truthfully, the goal) of these visits often becomes a long lasting relationship between the physician and patient which involves multiple visits, checkups and progress monitoring.

Complex, or complicated conditions are those which arise from various interactions between inherited traits ("nature") and environmental factors ("nurture"). One of the most immediate and identifiable examples of a complex condition would be cancer in its various forms. "More and more primary care physicians must not only identify medical needs of patients with chronic conditions, but they also must identify, coordinate, facilitate and manage issues surrounding and shaping these conditions such as lifestyle behaviors, food access, safety, and social, environmental and economic conditions," says Sharma. "That's not simple, primary care medicine. That's complex care medicine."

Indeed, when it comes to complex and chronic patient conditions, primary care physicians wear a host of differing "hats" to provide total and lasting healthcare to their patients.

Team-Based Care

The specific and long lasting nature of chronic and complex conditions, and the fact that primary care physicians are likely to be the physicians shouldering these burdens, highlight a push for more "team-based" care. Data from the study hypothesizes that, on average, primary care physicians would need 10.6 hours per working day to adequately care for patients with multiple chronic conditions, a serious time investment!

In these particular cases, patients would benefit from a team or network of care providers who can collectively help them execute treatment plans and coordinate care strategies with other providers and community resources. This would make great strides to delegate care and alleviate some of the burden from primary care physicians.

A Becker's Hospital Review article entitled The Affordable Care Act and Physicians: A Prescription for Change describes team-based care as a method for physician "capacity expansion." It's a re-interpretation, an evolution of the health care delivery model that employs the use of information technology and a re-design of the care delivery structure to account for a "team" of resources which care for patients. They suggest that medical practices establish procedures and policies geared towards each team member practicing to the highest level of their individual license, granting multiple team members, through the appropriate platform, access to information to best suit the needs of the patient.

The article also suggests that physicians adopt the best technology for the best purpose. As an example, primary care physicians, and other members of the care team, can utilize frequent communication with patients through various online platforms, including email. Chronic and complex conditions often necessitate long term communication, and an email can be just as beneficial for an entire office visit, and it's cheaper. Furthermore, physicians can invest more time in disseminating non face-to-face "touch points" with patients like e-visits, informational web pages and mobile technology.

A move towards a more "role-based" expectation model for staff members could lend greater responsibility to each team member. It will also involve some level of coordination and communication among team members, significant training on leadership skills and a structure put in place for team management.

Some Set-backs

Team-based care isn't without its own share of sticking points. For one, expanding the flow of patient information always introduces the risk of privacy breaches, especially when health information is being shared along a chain of command. It goes without saying that any changes made to patient information command would involve special protocol and security checks.

It can also affect payments and reimbursements. When physicians place a greater emphasis on disseminating health care information, they're taking their in-office services into an arena that's often not covered by Medicare or other insurance providers.

Finally, when the process of distributing health care is "shared" among a variety of professionals, patients may experience an extended time between their need for care and their actual treatment.

The Next Chapter

There's certainly no "magic bullet" scenario here. However, in an era where health care reform practically forces some elements of team-based care, and when primary care physicians are finding more and more of their time and services for complicated conditions being demanded, the need for delegation becomes increasingly crucial.

"Value based" health care, health care that seeks to improve the population's health while also increasing patient and physician satisfaction is a model that requires a fair amount of work, planning and re-structuring. It involves engaging physicians in assessing their health models and incentives, creating the most efficient platform that provides the best access to data and a "holistic" view of patients that extends beyond the office.

No one can definitely say where exactly reform will take health care, but the need for new care models may become apparent. With the right model, team and incentives, primary care physicians will continue to lead the charge for public health, regardless of the name we give them.

References

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Bendix, Jeffrey. "Building a Team-based Medical Practice."
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Centers for Disease Control and Prevention. "Asthma in the US - Growing Every
Year." CDC.gov. Centers for Disease Control and Prevention, 03 May 2011.
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Doerr, Tom, MD. "The Affordable Care Act and Physicians: A Prescription for Change."
Beckershospitalreview.com. Becker's Hospital Review, 4 Oct. 2013. Web. 15 Jan. 2014.

Physiciansnews.com. "'Primary Care' Doctors Should Be Called 'Complex Care'
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Praus, Julie. "Team-based Health Care' Can Be Costly and Slow."
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