Policy Bite: guest feature from the Robert Graham Center, USA

March, 2017

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This month's guest policy bite comes from the Robert Graham Center, in the USA, which aims to improve individual and population healthcare delivery through the generation or synthesis of evidence that brings a family medicine and primary care perspective to health policy deliberations from the local to international levels. The Graham Center team is made up of clinician researchers as well as a variety of social scientists from sociologists to geographers to economists. Supporting the work of the Graham Center is our Advisory Board, which provides advice and guidance to aid in navigating the important policy issues facing primary care
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Valuing, Measuring & Paying for Primary Care’s Foundations: Comprehensiveness, Continuity, & Coordination


The Paper:

More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations. Ann Fam Med May/June 2015 vol. 13 no. 3 206-213
Link to paper

The message:

- What was the context that made you write this paper?

Comprehensiveness is lauded as 1 of the 5 core virtues of primary care, but its relationship with outcomes is unclear. We measured associations between variations in comprehensiveness of practice among family physicians and healthcare utilization and costs for their Medicare beneficiaries. Other research has demonstrated that family medicine has high visit complexity, generally, as well as complexity density per patient visit.1,2 Furthermore, graduates of family medicine training programs in the United States want to practice a broader scope of practice than practicing family physicians are currently, perhaps reflecting a mismatch between what new physicians want to do and what the health system will support.3

- Why does it matter for patients?

Increasing family physician comprehensiveness of care, especially as measured by insurance claims data in a developed nation, was associated with decreasing costs and hospitalizations. This study may validate notions that patients receiving care from physicians with broader scope of practice are more likely to get “the right care, at the right time, in the right place” and avoid more costly care later.

- What should GP / FM leaders do to implement it?

Primary care leaders should advocate for payment and performance measurement that values and captures the essence of the primary care function. This study supports advocacy on behalf of measuring of physician or practice comprehensiveness in an age of reductionism. Specifically, it can be put forth in support of policies that incentivize enhanced comprehensiveness in primary care practice, noting their potential to help slow escalating health care spending. Measures which capture the important functions of primary care and are demonstrably linked to improved outcomes, should take priority over disease- and process-based measures. Governments and payers are often tempted to use the latter because the already exist and are typically easy to capture; however, when they are tied to financial rewards or penalties, they can drive care in unintended ways and reduce clinician motivation.4,5 We need better, and better tested measures of important functions in primary care, including comprehensiveness and scope.

The Authors

Andrew Bazemore MD MPH and Robert Phillips MD MSPH

Andrew Bazemore is a practicing Family Physician and the Director of the Robert Graham Center for Policy Studies in Washington DC. Dr. Bazemore has authored over 150 peer-reviewed publications, a developer of novel geospatial tools that use data to inform planning and policy, and on faculty at Georgetown University, VCU, and the University of Cincinnati. Dr. Bazemore received his BA degree from Davidson College, his MD from the University of North Carolina, and his MPH from Harvard University. He is an elected member of the National Academy of Medicine(NAM), and appointed member of the federal Council on Graduate Medical Education (COGME)

Robert Phillips is the Vice President for Research & Policy for the American Board of Family Medicine. He graduated from the Missouri University of Science and Technology and the University of Florida College of Medicine. He completed family medicine training and a two-year health services research fellowship at the University of Missouri. Dr. Phillips directed the Robert Graham Center, 2004-2012. He served as vice chair of the US Council on Graduate Medical Education, and currently serves on the National Committee on Vital and Health Statistics. Dr. Phillips is Professor in the family medicine departments of Georgetown and Virginia Commonwealth Universities. He was a Fulbright Specialist to the Netherlands and New Zealand, and is a member of the National Academy of Medicine.

Contact details

Email: policy@aafp.org
Twitter: https://twitter.com/thegrahamcenter

References

1. Katerndahl D, Wood R, Jaen CR. Complexity of ambulatory care across disciplines. Healthc (Amst). 2015;3(2):89-96.
2. Moore M, Gibbons C, Cheng N, Coffman M, Petterson S, Bazemore A. Complexity of ambulatory care visits of patients with diabetes as reflected by diagnoses per visit. Prim. Care Diabetes. 2016;10(4):281-286.
3. Coutinho AJ, Cochrane A, Stelter K, Phillips RL, Jr, Peterson LE. COmparison of intended scope of practice for family medicine residents with reported scope of practice among practicing family physicians. JAMA. 2015;314(22):2364-2372.
4. Glasziou PP, Buchan H, Del Mar C, et al. When financial incentives do more good than harm: a checklist. BMJ : British Medical Journal. 2012;345.
5. Roland M, Guthrie B. Quality and Outcomes Framework: what have we learnt? BMJ. 2016;354.