Primary care. Building a model for the new medical environment

A glance at the above list of requirements for a new model of primary care is enough to make most of us throw up our hands in despair! Any one of the several requirements above will be difficult to attain. The current payment system is largely based on Medicare specifications from 1965, and its faults have been obvious from the beginning. It creates incentives that lead to overemphasis on new technologies and to runaway costs. There is a growing concern that medical care is not meeting the needs of many in our society, and that we are not getting our money's worth. Large payer groups are beginning to think of alternatives, and demands for new solutions are growing. I am convinced that salary level is not the only, or even the most powerful, incentive in motivating most primary healthcare providers. They want an adequate, equitable, and comfortable reward for their services, and many would accept a lower level of salary in exchange for an opportunity to spend more time with--and do what they know is best for--their patients, in combination with reasonable hours of duty, recognition of their role, and system support. Is there anything a single provider or group of providers can do while we await payment reform? I believe so, but it must be realized that it will be difficult and might not help the physician as much as it helps the patient. Working with currently available tools, the primary care physician who wishes to move reform forward should try to implement the other two major changes. First, examine the practice unit, and make it a true team practice, as discussed above, meeting as many of the standards of the IOM-NAS report and checklist as possible. Second, examine the medical records generated by the practice unit and establish a computer-based system that can generate lab results, summaries, etc., as well as document, analyze, and improve the quality of the practice. I believe that records should be shared freely with patients, and patients should routinely be asked to read and validate them. Legally, they already have the right of access to this information. Why not ask them to share the responsibility for accuracy and completeness? It will probably make us more thoughtful about what we record. Certainly, we should freely share clinical information with patients, welcome their questions and input, and give them relevant information to enlarge their knowledge. These steps may not be a complete answer, but they will vastly improve the care given to patients. This should be justification enough to begin the process, while waiting for reform of the payment system that will rationalize the process. I have always felt that most physicians are primarily motivated to serve their patients in the best possible way. I hope that I am right!