UNC researchers: Many aspects of primary health-care system are broken, substantial systemic change is needed

By TOM HUGHES
UNC School of Medicine

 CHAPEL HILL -- Many aspects of the nation’s current primary health-care system are broken, and substantial change is needed for the system to remain viable and provide adequate access to quality health care, according to an analysis by University of North Carolina at Chapel Hill researchers.

“The strength of the organization of primary care has a major impact on the health of the population,” said Dr. Warren Newton, William B. Aycock distinguished professor and chairman of UNC’s department of family medicine.

Primary care, he added, is rapidly evolving as health-care providers explore new ways of responding to patient needs while also making their practices efficient and effective.

Newton is the lead author of an overview for a policy forum on innovations in primary care practice that was published in the most recent issue (May/June 2005) of the North Carolina Medical Journal.
That issue, available online at www.ncmedicaljournal.com/, contains eight articles by UNC authors, most from the department of family medicine. Most of the articles published under the policy forum’s banner were first presented as papers at a symposium on the issue organized by the department last fall.

The authors cited many indicators supporting their conclusion that “many aspects of our current primary care system – and thus the bulwark of the health of the population – are broken.” For example, almost one in five adults statewide have no health insurance. More than half of adults do not have a personal physician or other health-care provider.

About 17 percent of the state’s adults reported that they did not get needed medical care during the previous 12 months due, in part, to cost. As a result of these factors, the health status of the population by some measures is worsening, since those without health insurance or a personal physician die at higher rates and experience more negative outcomes for their health problems, Newton and colleagues wrote.
Primary care practices of the past were designed for short, problem-focused visits, the authors said. They were “organized around rapid triage for relatively simple problems, with short appointments emphasizing diagnostic tests, brief treatments and education.”

In contrast, primary care practices now need to provide substantially more chronic disease management and more comprehensive preventive services, they wrote. Complicating this transition is the failure of the traditional business model for primary care.

Newton’s overview reviews the history of the organization and community practice in North Carolina, assesses the current status of primary care and offers examples of promising innovations. Those innovations cited in the overview article include:

· Low-overhead business models for primary care practices, which reduce the cost of health care for both providers and patients. Two articles are devoted to this issue: one by Dr. Brian R. Forrest, a UNC family medicine adjunct faculty member who runs a low-overhead primary care practice in Apex; and one by UNC’s Dr. Steven Crane, family medicine residency director at Hendersonville Family Practice, which describes low-overhead practices that focus on indigent patients.

· Advanced access scheduling, based on the premise that patients should be able to secure an appointment the same day that care is needed. This is covered in an article by Drs. John Anderson and Carlos Sotolongo of Duke University Affiliated Physicians and a commentary by UNC’s Dr. Greg D. Randolph, assistant professor in the department of pediatrics.

· Disease management in the primary care setting. Two articles, one by UNC’s Dr. Thomas Wroth, assistant professor of family medicine, and Dr. Joseph Boals, of Sandhills Pediatrics; and one by UNC’s Dr. Samuel Weir, associate professor of family medicine, discuss quality improvement methods for managing children with asthma and other chronic diseases in community practices.

· Electronic health records. The benefits and challenges to primary practices of converting from traditional paper-based medical records to electronic health records are discussed in commentaries by Dr. Karen Smith, president of the North Carolina Academy of Family Physicians and a UNC family medicine adjunct faculty member; and Dr. Edward Ermini, in private practice.

· Electronic communication with patients and payers. UNC’s Dr. Donald Spencer, professor and director of the UNC Family Practice Center, describes the initial experience of establishing a Web-based interface with patients in a family medicine setting. Dr. Eugenie M. Komives, the senior medical director for network services at Blue Cross and Blue Shield of North Carolina, discusses the insurer perspective on reimbursement of telephone communication.

· New models for community-based care. UNC’s Dr. Allen Dobson, professor of family medicine and president/chief executive officer of Cabarrus Family Medicine, describes the development of a pilot program by Community Care of North Carolina in Cabarrus County, while Dr. Charles F. Willson, president-elect of the North Carolina Medical Society, describes the development of a similar CCNC program in Pitt County and the statewide organization. Such programs are being implemented in most counties statewide.

The editor-in-chief and publisher of the North Carolina Medical Journal is Dr. Gordon H. DeFriese, a former director of UNC’s Cecil G. Sheps Center for Health Services Research. DeFriese, who still serves as a senior faculty fellow at the Sheps Center, also is a professor of medicine, dental ecology, epidemiology and health policy and administration at UNC. He co-wrote an introduction to the policy forum.

UNC School of Medicine contact: Stephanie Crayton, (919) 966-2860 or scrayton@unch.unc.edu