Dr. Ed Wagner

Last week I attended a lecture that was part of the "Prevention and Chronic Care Management" conference hosted by the College of Public Health. Dr. Ed Wagner was awarded the Richard and Barbara Hanson Leadership Award and Distinguished Lectureship (I think the only thing academics love more than acronyms is really loooong names). I would have loved to attend the full conference, but other duties called my name. His lecture was titled "Primary Care and the Future of American Medicine." The title itself was compelling enough to rouse me from my bed before 9 a.m. (a monumental feat). But wake I did and I am very happy for it.

Dr. Wagner’s speech was titled “Primary Care and the Future of American Medical Care.” He began his speech by looking at the current state of primary care. For the purposes of this speech family medicine, internal medicine, and pediatrics were the specialities considered to be “primary care” (some sources also define psychiatry as a primary care field). From 1999-2009 the percentage of medical students choosing family medicine dropped from 15% to approximately 7%. Internal medicine fared even worse with a drop from 13% to 2%. In addition to fewer students entering these specialities, more current practitioners are leaving.

Why does the decline of primary care even matter? For several reasons: countries with better primary care have better health outcomes and lower costs, U.S. states with higher primary care/population rations have reduced costs and better quality. A survey asked if it was important to have “one practice/clinic where doctors and nurses know you, provide and coordinate the care that you need.” 95% agreed that it was important, 85% of those “strongly agreed” with the statement. The decline of primary care physicians per capita has also led to significant declines in satisfaction with the multiple areas of primary care, such as doctor-patient communication, interpersonal treatment, thoroughness of physical exam, visit-based continuity, and care integration.

What is the reason for this decline? One is that as the population grows older and sicker, PCPs are responsible for more content, increased demand and increased complexity. Other reasons are declining income and working harder to just keep up (“hamster wheel”).

Dr. Wagner's has done extensive work in chronic care and this is where the rest of the talk headed. He noted the increase in chronic conditions and how chronic conditions exponentially increase health care costs. One slide showed chronic conditions of medicare beneficiaries: 65% of beneficiaries had two or more chronic conditions and incurred 95% of expenditures! Chronic conditions have always been complex, but with new medications (which are often used in combination with each other) and ever-changing guidelines, the complexity has become even greater. This has affected the ability of the patient to manage his/her own care as well as resulted in a decreased ability of providers to support and educate patients regarding their care. What is the result of all this? "Patients with major chronic illnesses receive recommended care about 1/2 the time."

So, we need a way to combat declining primary care physicians, declining outcomes, and increased costs. The current buzzword is the medical home. The medical home initially grew from the American Academy of Pediatric's pediatric medical home. When combined with the chronic care model, one comes up with the patient-centered medical home (PCMH). The PCMH is a topic too large to discuss in this post, but the central idea is that each patient has a primary-care provider that is their first point of contact for health care and is the person that each subsequent encounter (PCP visit, specialist referral, hospital admission) refers back to. 

The PCMH has been shown to be effective in improving outcomes, but it still faces roadblocks to widespread implementation. Many providers are lacking the IT and infrastructure that is essential to a medical home and the current payment system doesn't reimburse for coordinating functions.

I highly suggest that everyone reads more about the patient-centered medical home as well as the chronic care model.