Monday, 29 December 2014

Deconstruction of primary care

The renowned Harvard professor Michel Porter, with the collaboration of two GPs, one veteran, Thomas Lee, and the other on training, Erika Pabo, applied to primary care their well known proposals of adding value to clinical performances. Their article, published in Health Affairs, caused me to act cautiously because I didn’t believe any American proposal of reforming primary care could benefit us as we enjoy a much more evolved model. But when I noticed that the first author was Michael Porter, I couldn’t help taking a look.

Primary care (gatekeeper type), Porter and his colleagues say, is now served on a single dish, like a stew (they don’t actually say that). Continuous care prevails, always the same chef for every meal, an almost artistic development, case by case, plate by plate. According to them, this makes it difficult to measure the provided value. On the other hand, the most common model in the US, where the patient goes to a specialist in their own terms, is chaotic and promotes a disproportionate consumption of resources.

Between the two extremes, the authors propose a deconstruction of the gatekeeper model into 5 population subgroups (if you’re interested you’ll find them described in the appendix of the article):
  1. Subgroup of healthy population (approx. 36%)
  2. Subgroup of healthy population suffering a relevant acute pathology (variable)
  3. Subgroup of population at risk of becoming ill (approx. 18%)
  4. Subgroup of population with one or more chronic conditions (approx. 45%)
  5. Subgroup of population with complex diseases (approx. 5%)
According to Porter's model, a specific team for each of the subgroups should be defined. It would be recommended that hospital specialists would be integrated (especially in the subgroup 4 and even more in 5) into these teams to share clinical practice criteria, treatment plans, transfers between primary care and hospital and, in short, facilitate the flow of clinical information between different levels.

Following this model, the goal of these professional teams would then be the continuity of care for citizens assigned to their subgroup. And to be able to be identified as a clinical management unit, they should measure the clinical outcomes to which they committed, they should be able to know the costs of major processes, they should be paid in the form of a "bundle payment" (per head adjusted to each subgroup), and finally, they should be able to compete on values (effectiveness) and not on other considerations.

Some noteworthy Porterian model ideas for primary care
  • The subgroups 1 and 4 could be led by nurses
  • The units should be able to revise the efficiency, cost and outcome data monthly
  • The professionals should have performance-linked incentives (economic and non-economic)
  • An online "two-way" communication with patients should be promoted
  • Group 5 should develop an intensive program for home care
This Porterian model is disruptive with regards to the "holistic" view of the gatekeeper model. The article's authors admit it, though argue that with a little skill, one can achieve the maintenance of personalized treatment, but also add the benefit of efficiency and clinical effectiveness.

It also should be noted that the article opens the door to continue the traditional model for unclassifiable patients. I also want to note that the authors do not shy away from talking about the model’s obvious limitations when it comes to extending it to rural areas and in order to overcome these limitations, they call for the promotion of networking as the only way that the new model can reach as far as possible.

Despite the weak and disorganized US primary care status, I think this Porterian project offers some rather well informed and useful ideas.

Jordi Varela

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