By Thomas Bodenheimer
Health Affairs, March 2012
“Breaking Point: How The Primary Care Crisis Endangers The Lives Of Americans”
by John Geyman
Friday Harbor (WA): Copernicus Healthcare, 2011
234 pp.; $18.95
Many innovations in health care falter. New drugs, hastily approved, can disappear in a flurry of bad outcomes. Medical devices (some metal-on-metal hip replacements, for instance) turn into disasters for those who have them. Certain attempts to improve quality might be oversold and fail to live up to their initial hype; pay-for-performance comes to mind. In health policy, so-called tipping points[1]— times when new ideas spread rapidly to become the norm—are few and far between.
An innovation that “tipped” successfully into place in the recent past is the hospitalist movement, in which hospital-based general physicians handle care for hospitalized patients in place of the patients’ primary care physicians. It took the nation by storm in the 1990s and, for better or worse, changed the way both in- and outpatient care are delivered. Coming now to the innovation forefront is the patient-centered medical home—also known as “transformed primary care,” “twenty-first-century primary care,” and “the primary care of the future.”
John Geyman is someone whose opinion on this new innovation counts. In the 1970s he was one of the founders of the new specialty of family medicine, and he has enjoyed a long and productive career in his beloved primary care.
“Breaking Point,” Geyman’s new book about primary care, reviews the promise and problems of primary care. His analysis leads the reader to wonder whether the medical home will reach a tipping point (success) and permanently transform primary care or a breaking point (failure) and be a short-lived blip on the health policy radar screen. Despite the book’s title and recounting of the difficulties facing primary care, the author seems cautiously optimistic that primary care will grow and thrive. The book has a clear point of view, which is that a single-payer system is a prerequisite to a strong primary care sector. It is well written, informative, evidence-based— and an important book for everyone concerned about the U.S. health care system.
Geyman begins by reviewing the evidence base and essential elements of primary care—much of it on the basis of work by the field’s intellectual giant, the late Barbara Starfield[2]—and primary care’s role as the foundation of any health care system. From there, Geyman turns to the serious barriers facing primary care today in the United States: a growing physician workforce shortage in the area of adult primary care, poorly organized primary care practices, and the impossibility of primary care’s being able to provide accessible, high-quality care when doctors have overly large patient workloads.
But “Breaking Point” is not a despairing or complaining book. After laying out the challenges to building a viable primary care foundation for U.S. health care, Geyman goes on to highlight examples of the enormous energy for improvement that infuses hundreds, if not thousands, of primary care practices around the United States: “The Organized Team Model is ideal for building primary care capability to care for populations in a wide range of practice settings.…[It] offers concrete ways by which year round 24/7 primary care can be provided to populations on a sustained basis.” He continues, “Despite decades of deterioration, some promising developments portend a brighter future.”
This outpouring of innovation and energy that Geyman writes about leads primary care advocates like me to believe that the patient-centered medical home—by whatever name it is called—will, indeed, reach a tipping point and spread widely and well throughout the country.
The early adopters of transformed primary care are community health centers and integrated health care delivery systems. Programs such as the Vermont Blueprint for Health and Group Health in Washington State—both known for their improvements in access, prevention, and quality—are two of the innovations described by Geyman that are showing the way. Yet Geyman is cautious about innovation alone, noting that although “these new grassroots efforts to bring primary care into the 21st century give us some hope of their success, much broader system reform will be required to gain that result.”
His larger prescription includes single-payer universal health insurance, primary care teams, giving doctors a generalist orientation during their medical education, and payment reform. On the specifics of payment reform, Geyman argues that insurers’ payments to primary care practices should not reimburse doctors alone but should also should pay for the work of the entire team. Payments also should recognize primary care’s contribution equally with that of specialty practices.
Geyman does not provide details on how primary care practices might transform themselves. A useful addition to the book might have been a more detailed description of high-performing, well-organized practices—whether a small community health center in South Carolina or a huge integrated system in California—because they are remarkably similar in how they transform themselves.[3]
The bedrock needed for this transformation to succeed is continuity of care, which is well known to improve patients’ and clinicians’ satisfaction, improve quality outcomes, and reduce costs. Patients are affiliated with a specific primary care clinician (a physician, nurse practitioner, or physician assistant) within a group practice, and as often as possible they see that clinician, forming a relationship of trust that also improves outcomes.
Not only does this transformed primary care practice place a priority on continuity, it also ensures prompt access for patients. The capacity needed to meet the growing demand for primary care services is created by having a team—consisting of both professional and nonprofessional providers—deliver health care for a group of patients. In high-performing practices, patients transfer their trust in the doctor to trust in the entire team.
Yet, as Geyman emphasizes, these changes are not easy to accomplish; they require the larger system change cited earlier. “Breaking Point” provides information on both the promise and the challenges of primary care and then gives readers the confidence that transformed primary care can reach a tipping point and become the standard way in which primary care is provided in the United States.
Thomas Bodenheimer (TBodenheimer@fcm.ucsf.edu) is a primary care internist who was in full-time practice for thirty-two years. He is a professor of family and community medicine at the University of California, San Francisco.
NOTES
1 Gladwell M. The tipping point: how little things can make a big difference. Boston (MA): Little Brown and Company; 2002.
2 Starfield B. Primary care: balancing health needs, services, and technology. New York (NY): Oxford University Press; 1998.
3 Bodenheimer T. Lessons from the trenches—a high-performing primary care clinic. N Engl J Med. 2011;365:5–8.
doi: 10.1377/hlthaff.2011.1389