Is primary care losing it from the hospital?

Health care finds itself in a period of drastic change. Care organizations more often have to profile themselves as value-driven companies. Governments and health insurers are experimenting with new funding models, which expose healthcare providers to bigger financial risks. In order to better manage these financial risks, new organizational models are being developed. In practice this means a far-reaching integration of primary and secondary care. However, this is not happening without a struggle, as proven by discussions that are currently going on about how to realise integrated care in practice. Integration of care proves difficult to achieve because we continue to work with sector-specific and therefore fragmented budgets and organizational models. In this blog, we discuss which organizational models do deliver added value by integrating primary and secondary care.

Beyond the fragmentation

The integration of care for people with complex care needs proves to be a problem in the Netherlands. The introduction of integrated care has ended in failure. There is a lack of integration between primary and secondary care providers. The care for chronic diseases is not integrated with medical specialists from the hospital. In many countries, the healthcare sector neglects to work in a coordinated way between general practitioners and medical specialists, and also to ensure that governance and financing fit in with this. This has caused fragmentation of care, whereof complex patients with multiple chronic disorders – a group which continues to grow – has become the main victim. These people need integrated care, whereby primary and secondary care providers cooperate to a large extent.

Global lessons learned show us how we can break this impasse. Using two value-based healthcare models from the US, we will show you that it is time to tackle things differently. Both models have been scientifically proven to bring about a significant improvement in terms of quality and cost savings. They have thus proven their value and could well serve as a starting point for other countries.

Patient Centered Medical Home

The first model, Patient Centered Medical Home (PCHM), dates back to 1967 and is therefore one of the oldest value-based care models. The model is based on the ideas of American professor Barbara Starfield. She fought for a people-oriented approach to patients and for strong primary care that guides people through the jungle of care facilities. And that is what happens in a PCMH. A GP or other primary care provider, chosen by the patient, is responsible in this model for planning, delivering, coordinating and monitoring patient care, both within the organization and throughout the continuum of prevention, care and well-being. The needs of the patient are central to this.

Within a PCMH, care is provided 24/7 by a multidisciplinary team of care providers (text box 1). The focus is not only on the demand for medical care, but also on a people-oriented approach. This means, for example, that there are also (care) programs that focus on the social domain, such as poverty reduction. This results in a total package offered with the aim of keeping people as healthy as possible. Patients are actively involved in “managing” their own health better.

A PCMH is based on the principles of population management and continuous improvement processes. Proactive data management is also taking place. This means that everything around the patient is monitored: laboratory results, hospital admissions, referrals, etc. Everything is laid down in clear guidelines, protocols and checklists. There is a lot of research that demonstrates the added value of PCMH in terms of costs, health care use and health.


Accountable Care Organisation

An Accountable Care Organization (ACO) is formed and managed by various healthcare providers from primary and secondary care. Care is provided across the entire care continuum. An ACO can be managed by, for example, general practitioners, independent medical specialists and/or health insurers. The parties working together in an ACO are jointly responsible for the total care for a patient population with regard to quality and costs. Those two are inextricably intertwined. The improvement of care due to the improved quality ensures better results, which in turn leads to lower costs. The focus on cost regulation stems from the origins of this care model: the Obama Care Act. This health care law obliged Americans to register for health insurance.

An ACO works on the basis of indicators in the area of quality, costs and coordination that have been jointly established (text box 2). The benchmark has been determined for these indicators, after which quality criteria and rates have been determined. The providers are part of a fee-for-service as well as a value-based care contract (i.e. a bundled payment or shared savings/shared risk contract). This means that they are exposed to a certain financial risk, but also benefit when profits are made. Proactive data management keeps track of how individual healthcare providers are performing on the various indicators. Finally, ACOs benefit from well-organized primary care. Because the more efficiently primary care is organised – for example, by setting up a good gatekeeper function – the more you earn as an ACO.


The difference between a PCMH & ACO

When you compare a PCMH to an ACO, you’ll see that a PCMH is much more focused on coordination of the care process, while an ACO is more focused on the cooperation between organizations. Table 1 below shows the differences between a PCMH and an ACO.

Table PCMH vs ACO

Regional organizational strength

The concepts of PCMH and ACO are good examples of value-based care models that can also be applied in other countries. Both models show that the answer to better outcomes must be sought in an integrated care approach. In the transition on the way there, the question is whether larger (regional) hospitals or smaller primary care facilities will be in the lead. Actually, this discussion should not be conducted, because what should be done is strive for the best, most efficient and people-centred care for the patient. This can be achieved through better coordination of prevention, care and well-being. Research has repeatedly shown that a primary care system is and remains the basis for a value-based approach.

The primary care Calimero complex

However, the primary care seems to be increasingly side-lined in countries like the Netherlands, because the organisational power leaves a lot to be desired. Primary care organizations have too little mandate from their GPs and are too much steered by the issues of the day and experienced work pressure. In that respect, the hospital has a head start, as a result of which healthcare financiers are now moving more towards them. But the approach that financiers have in mind does not solve the problems at hand. What is needed is a step back. Back to the drawing board. A fresh start. For a hospital, the ACO proves to be a very interesting model for a regional care approach, but first the primary care needs to be better organized.

On the road to equality

Without a well-organized primary care system, value-based healthcare is impossible. The PCMH concept can strengthen the organisational power of a primary care organisation. It lays the foundation for well-coordinated and organized 24-hour care service and offers many tools on how the organizational strength of primary care can be improved. The organisational power of primary care is a prerequisite for experimenting with a concept such as an ACO. Only then can primary care be an equal partner for the hospital and the medical specialist.

You can read more about how these two care models can be used to implement value-based healthcare in our whitepaper.

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dr. Pim Valentijn

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