Monday, 1 May 2017

Primary care: segment to reform?

In a paper published in Health Affairs, Redesigning Primary Care: A strategic vision to improve value by organizing around patients' needs (see commented post) Michael Porter invited us to rethink the organizational model of primary care in accordance with the real needs of the population.

Following the Porterian advice, and just to think a little, it’s worth the excellent Memory of the Catalan Institute of Health (ICS) of 2013, with data from 288 primary health care teams spread throughout the territory, from small local clinics to metropolitan centres with several basic health areas under their care. On page 7 of the document you will see a table elaborated with the attendance of more than 4 million people (who have been visited at least once during the year). The segmentation of this population, grouped with Clinical Risk Group, shows that segments 5, 6 and 7 (different intensities of chronicity) have represented 64.5% of the people who have visited, a group that has consumed 88.8% of the pharmacy and generated 74.7% of urgent hospitalizations (among patients who have been hospitalized two or more times in a year).

If you jump to page 8 of the document you will see an activity chart that collects information from more than 36 million visits to ICS primary care units, of which slightly more than half (52.2%) were physician visits and only 33.5% were visits to the nurse. Whilst keeping segmentation data within sight, look at the figures for the activities that would seem most appropriate for chronic patients: telephone consultations, remote consultations or home visits.

The percentages are on the total activity of doctors and nurses

The relative low activity of the three care modalities collected in the table is a sample of the disagreement of an organizational model designed to guarantee accessibility and the gatekeeper function, with the high prevalence of chronic patients that reflects the segmentation, so it would be convenient to start to redefine the model, along the line indicated by Michael Porter, or already practiced by Kaiser Permanente, according to a new way of organizing primary care that preserves basic values ​​(accessibility and gatekeeper) but is able to adapt the reforms to the real needs of the different population segments.

In the light of segmentation, the organizational model must be reworked according to the needs of the most typical segments and, therefore, the scheme of a doctor and a nurse who are responsible for all the needs of a given population does not seem to be the most suitable for our times. The specialization of primary care teams must arise from the integration of services to serve specific population groups and, if not, what is the point of stratifying risk and complexity if there is no will to reform accordingly?

Jordi Varela

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