The primary care physician and the Triple Aim – A team effort

There is a lot expected of the primary care physician (PCP) when he or she engages in a value-based care arrangement. Reducing total cost of care for a patient population that is part of a 2,500 patient panel is no easy task. While the PCP directly receives very little of the revenue generated by the healthcare system, they can influence a large proportion of the cost and outcomes. This influence is established directly through being the first and ongoing point of contact for the patient, as well as their role in recommending and referring patients to specialists, ordering diagnostic and lab tests, and prescribing medications.

The 15-20 minute interaction between a PCP and patient is a narrow window to accomplish the ambitious goals set forth by the Triple Aim, which include improved outcomes, lower costs, and a positive patient experience. Along with spending time with patients, the PCP is expected to enter findings in an electronic medical record, write prescriptions and make referrals, and review laboratory tests, imaging reports and consultation notes. This doesn’t even include phone calls, email, or filling out insurance forms.

Clearly, the PCP can’t do it alone. Just managing standard visits for coughs, colds, back pain, and skin problems is enough to keep most PCPs busy throughout the day. These acute conditions are not even the ones that are driving the costs, since 86 percent of healthcare spending is for people with one or more chronic conditions. Being proactive and regularly following up with chronic patients, which includes glycemic control for those with diabetes, controlling hypertension and hyperlipidemia, and outreach to the highest risk patients is a daunting undertaking.

Healthcare providers that are often called “physician extenders,” such as APRNs and physician assistants, have become PCPs in their own right. There are other categories of health professionals that may provide the majority of care or counsel to specific types of patients, such as mental health therapists, chiropractors, and pharmacists. While critics often site care coordination and inappropriate expansion of practice scope as the key reasons for maintaining primary care physician as the exclusive primary care provider, there are good reasons to include other healthcare professionals in primary care.

Even if primary care physicians had unlimited time to spend with patients, they don’t have unlimited knowledge or training. One example is in the area of nutrition. Medical schools offer an average of 19.6 hours of nutrition education across 4 years of medical education, despite the well-established link between poor nutrition and chronic diseases such as obesity, diabetes, hypertension, heart disease, and cancer. Nearly all patients with these nutrition-related diseases would benefit from consultation and ongoing instruction from a dietician or nutritionist.

Behavioral health is another key area where primary care physicians do not feel like the expert, yet 20 percent of all primary care visits include some type of behavioral health intervention.  When primary care physicians can work directly with care managers, including social workers, nurses and psychologists that focus on mental health treatment, deaths can be avoided and lives can be improved.

The challenge for a healthcare system that is moving from volume to value is to develop programs that give the primary care physician the best chance of success. This may be best accomplished by acknowledging the PCP’s limitations with respect to time and training, and expand the opportunity for other healthcare providers to be incented and rewarded for their role in improving outcomes and reducing costs.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.