The Chief Primary Care Medical Officer: Restoring Continuity

What strikes me after reading this well-written and thoughtful Annals article by Doohan and DeVoe is how a much simpler and superior approach would be a culture change in health care - whereby every patient is expected to have a committed PCP; and expected to themselves be committed to routine follow up with the PCP. Dr. Saultz's comment above that the issue is 'in our hands' rather than being in the hospitals' purview is noted and emphasized by my own experience and assessment; as is Dr. Glaser's observation that this approach of adding a new management role adds bureaucracy, complexity and expense. A bilateral committed relationship between a given patient and her / his PCP would obviate the need for the authors' proposed system. Patients should understand that when they enter a hospital, they notify their PCP; and the PCP should initiate and maintain timely unbroken contact with the hospitalist team as well as the patient's caregivers until discharge. The root problem is not with the hospital, or the hospitalist; but rather, with the profession of primary care physician, having lost this dedication to continuity on our end - exchanging it for paperwork, payment-based workflows, and other distractions. One solution which would negate the need for the CPCMO is a white board at every clinic containing the names of all patients of the practice who are in a hospital that day, and a commitment by the PCP team to make daily contact with the hospitalist and patient family until at discharge the name is erased and follow up is secured.

One final thought here is to respectfully challenge the notion in the article that "The volume-based, fee-for-service paradigm that has characterized the US health care system for decades is unsustainable" and the assumption that value-based payment is the decisive solution. The past 8 years of national experience with the novel models such as PCMH and ACOs have failed to solve the original problem of the 'Triple Aim' and have instead added the quality of life issue with medical staff, such that now we have the 'Quadruple Aim'; as well as given birth to the new era of urgent care and retail clinics, telemedicine visits, mid-level practitioners replacing PCPs in managing highly complex patients, and free -standing ERs on every corner. A return to fee-for-service - but in the context of highly-committed PCP-patient relations and not based on volume - is likely in order. The concluding statement of this article argues against a 24/7 approach; but indeed, that exact kind of access between the patient and the PCP team may well be a key element in solving the broken U.S. health care system - a situation that 'value-based' payment and 'population health' approaches are not only failing to help, but arguably making worse.

Competing interests: Developing a consulting firm assisting primary care clinics

Excellent article by Doohan and DeVoe. I have been a Chief Primary Care Officer at Eisenhower Medical Center in Rancho Mirage, CA since 2009. Primary care went from being weak to strong. Our group went from three physicians to 60. We started two primary care residency programs. Our executive leadership team has two physicians, the Chief Medical Officer and me. Primary care leadership sends a strong statement as to the value of primary care.

Competing interests: None declared

Dear Dr Saultz. Thank you for your wise response. I agree with you that stronger primary care is the best solution. As more hospital based health care systems expand into being providers of both inpatient and outpatient medicine, the primary care function in my experience is increasingly centered in the hospital where decisions are made about primary care without the presence of leaders who are primary care experts. I hope that the CPCMO would also, in addition to being an "ombudsperson", be a mentor for hospital leadership in terms of the best and most effective primary care practices. yours truly, Dr Noemi Mimi Doohan

Competing interests: None declared