The Future of Primary Care
Ed Wagner, MD, MPH, MACP
MacColl Center for Health Care Innovation
Group Health Research Institute

Why worry about the future?
“I look to the future because that’s where I’m going to
spend the rest of my life”.
George Burns
2

Only 8 years ago
Primary care
providers are
dispirited, burning
out, and diminishing
in number.
Primary Care —
Will It Survive?
Bodenheimer T. N Engl J Med. 2006

Percentage of medical students choosing
primary care specialties
0
5
10
15
20
Family
Medicine
General Internal
Medicine
Pediatrics
1999
2009

5
Percent
Physician Satisfaction with Practicing Medicine
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

What’s Threatening Primary Care?
Changing demography and
practice content increasing
demand
Greater care complexity
Working harder and harder
just to keep up
Professional isolation
Declining real income

But then hope!
• Federal healthcare reform is counting
on a robust primary care sector to
improve quality and reduce costs.
• “The Patient Protection and Affordable
Care Act (PPACA) of 2010 … has the
potential to reestablish primary care as
the foundation of US health care
delivery.”*
*Goodson J. Ann Int Med. 2010; 152:742

The ACA is betting that more effective primary care
reduce health care costs?
Effective primary care will lower total costs by reducing
hospital admissions and ER visits.
How? By taking better care of individuals with multiple
chronic illnesses—aka complex patients.
The future of primary care may well depend on its ability
to manage complex patients well.
It was abundantly clear that traditional, doctor-driven,
reactive practice is not up to the task; we needed a new
model.

For primary care to re-establish itself as the
foundation of American healthcare, it will have to
manage complex patients well, the very group that
may be contributing to its existential crisis.

The Questions
10
• Can primary care effectively and manage complex
chronically ill patients?
• Can primary care reconnect with hospitals and specialists
to improve care sharing and coordination?
• Can primary care once again be an attractive career option?
• Will primary care get the resources it needs to truly
become the “foundation of US health care delivery”.
• Will hospital driven ACOs consider primary care as its
foundation or a cost center?

Primary Care Teams:
Learning from Effective
Ambulatory Practices
“The future is here. It’s just
not widely distributed yet”.
William Gibson
Dr. Margaret Flinter – co-Director

Collect data on innovations and change
processes, best practices
Collect data on innovations and change
processes, best practices
Develop a toolkit for broad
dissemination
Develop a toolkit for broad
dissemination
Create a learning community among
exemplar sites
Identify up to 30 exemplar sitesIdentify up to 30 exemplar sites

30 LEAP Sites

What are we learning?
LEAP practices view performance as a system property,
not a function of how smart everyone is.
LEAP practices measure performance by provider and
regularly review it.
LEAP practices are constantly changing, trying to
improve.
LEAP practices innovate “because it is the right thing to
do”, regardless of reimbursement.

LEAP sites really understand the functions
that lead to higher quality and lower costs
Team Care
Population management
Planned, proactive care
Self-management support
Medication Management
Care management/Follow-up/Care Coordination
Cost-effective specialty input
TO “really understand” a function means hard wiring it into
your care system—staff training, IT, work flows.

It begins with Skilled and Well-organized Care
Teams
Involvement of non-physician care team members in care has
been associated with a 0.75% reduction in HbA1c and a 13
mmHg reduction in BP.
Without effective teams, practices find they can’t do many of
the other functions.

What have LEAP sites
done to create effective teams?
Hire bright, energetic folks with
good interpersonal skills.
Define key roles and tasks and
distribute them among the
team members (everybody at
top of their license).
Train staff to perform tasks.
Use protocols and standing
orders so that staff can operate
independently.
Give teams time to meet.

Population Management
Many of the deficiencies in care quality relate to the
reactive nature of medical care.
Defining panels and developing and using IT tools to
assess the panel to identify care gaps was a key step .
LEAP sites link assessment with outreach. May account
for the biggest leaps in clinical performance.

LEAP site deliver planned care
19

How do LEAP sites implement self-
management support
20

Medication Management
Protocol-based prescribing and monitoring of adherence and
outcomes is associated with better outcomes.
LEAP sites view medication reconciliation as a critical
intervention for both patient and practice.
Pharmacists and RNs can play important roles in complex
med. rec., titrating medications, and addressing non-
adherence and other drug problems.
21

Planned follow-up and Care Management
(outside of visits)
Follow-up can range in intensity from periodic status checks
by telephone or e-mail to active care management.
LEAP care teams regularly monitor patients (evidence-based!).
Higher risk patients (poor disease control, frailty, etc.) benefit
from regular follow-up (monitoring) AND active care
management.

Care management
23

24

Is practice in a LEAP site more
satisfying?
All staff Physicians
Most people in the
practice enjoy their work 79% agree 84% agree
This practice is a place of
joy and hope 64% agree 69% agree
People in our practice
actively seek new ways to
improve
92% agree 94% agree
25

The Questions
26
• Can primary care effectively and manage complex
chronically ill patients?
• Can primary care reconnect with hospitals and specialists
to improve care sharing and coordination?
• Can primary care once again be an attractive career option?
• Will hospital driven ACOs consider primary care as its
foundation or a cost center?
• Will primary care get the resources it needs to truly
become the “foundation of US health care delivery”.

A. Goroll, NEJM December 2008 27
“The solution is not an intramural “food fight”
over payment. The way to get money redirected
to primary care is to improve care management
and coordination by the primary care
physician.”

www.improvingchroniccare.org
Watch for:
www.improvingprimarycare.org
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