The Capacity of Primary Care for Improving Evidence-Based Care: Early Findings From AHRQ’s EvidenceNOW

The Annals continues to do a great job. Kudos for Dr. Casalino who's been paying attention to small practices for years.

For over a decade primary care has been pounded to fix itself and all of the sudden do things no one's heard of or has the tools for, like population health. We had a brief attempt at an extension service here, what they did was just get everyone to buy a certain EMR at a discount.

Shared services? Sounds great, how? Share a MSW? Who hires? Who pays the payroll taxes? Is there telehealth? What platform? Bring me solutions. This issue largely describes more top down programs with non-physician facilitators who want to engage us with their work.

We cannot transform ourselves unless we have tools to do it. No one is talking about the things I need. I need to buy vaccines in unit doses. Vaccine management sucks off hundreds of dollars from practices every year. We need an app that takes the fridge temp right to the website and we need interfaces to take immunizations to the state registry. No one talks about buying vaccines in unit doses, yet all it takes is for the manufactures to change the NDC code, as most of them are made in single doses. Our professional societies have failed us. This is actionable.

There are other actionable things that go unaddressed. We cannot continue to criticize primary care and reduce its scope of practice, and then tell us that it needs to transform itself. Obviously docs have often drunk the Kool-Aid that they are too busy so yes take Coumadin management away, yes put wounds into a special clinic, and send diabetes elsewhere. A local hospital has an osteoporosis clinic! What next? When we reduce scope of practice we never get it back. When we are not allowed to code for psych med management or cutting toenails, we stop providing services or exhaust ourselves with work arounds. And all of this, all of this ignores what Uwe Reinhardt kept saying about the real problem "it's the prices".

We need to stop asking PCPs to work for free to get ortho and opthalmology paid 3 times what we can make, because the optometrist needs me to refer to ophthalmology for cataract surgery and the fx in the ER needs me to refer to ortho. When we demean professionals, what transformation can rise up out of that?

Let's remove the restriction for prior auth for a CT for suspected appendicitis. ONE CONDITION. Because I just send them to the ER for $600? $1,000? Better that than $100 of time out of my pocket. Payers and PCPs could have a win-win on that as well as covered e-visits. I have patients pay $25 to $35 for conjunctivitis, uti etc. 24/7/365. But payers would rather pay 2 or 3 times that and, make the patient come in.

Transformation by PCPs? I have seen everyone the day they have called and on time for 13 yrs. MY folks are not in the ER or readmitted. I measure. And I am exhausted. I think we need to go to the AAFP and the payers and CMS and do some facilitating with them. Then I can do my best.

Let's eliminate the morass of coding and billing. It takes some of us longer to code a visit than to take care of the patient what with modifiers and checking to see if they can have that visit in a calendar year or within 365 days, with the risk of patient anger when they get a bill for the E and M part of what they are told is a checkup. I protest that I have to continue to be a good dog on the backs of my family's income. Payers, legislators and professional societies need to step up to the plate and transform, because then I bet magically a lot of us who manage to still go to work every day would remember why we are here and be able to do an even better job than the one we manage now.

It's well-known that when you just criticize people with what is wrong with them (as Maine Quality Counts came out and told me that practices "like mine" could not be a medical home) and despite hating it, since I had already "transformed", I became a level 3 NCQA "home" twice now. Top down meet- the -facilitator -about- one -disease metric does not engage even deeply caring people. We keep doing that, we keep doing the same things over and over :) But when you give professionals the expectation that they are great, and real tools to do a good job, people give back and work harder. We need to change a lot of attitude about primary care in this country, because there's a lot of a lot of talk but no meaningful walk.

Competing interests: None declared