A Practical Plan to Deliver the Quadruple Aim in Your Primary Care Practice Consistently
New science, new systems, and new payment models make it possible to modify your practice to produce the quadruple aim consistently but the current system will never do it. The slide above shows the most common conditions in an internal medicine practice in order of visit frequency and the revenue from those conditions. The frequency of visits would be similar in an adult nurse practitioner practice. The three most common conditions are hypertension, high cholesterol, and type 2 diabetes. Heart artery disease and other cholesterol issues are also very frequent and related to the first three. Fully half of the most common adult primary care visits are cardiometabolic. Adult primary care practices contain many patients with chronic kidney disease and heart failure as well. These conditions are all related and optimal medical therapy produces better outcomes at lower cost for the patients who have them. Don’t refer these patients. With optimal medical therapy you can retain them in your practice and provide better care while making your practice more secure financially.
In our current system, if there is hypertension that is not responding, the primary care provider frequently refers that patient to a cardiologist. For type 2 diabetes and cholesterol issues they may be referred to an endocrinologist. Heart artery disease is almost always referred to cardiology. Optimal medical therapy protocols and systems can provide better health at lower cost for most of these patients within the practice and without referral. That would drastically reduce fragmentation of care, gaps in information, duplication of studies, and patient confusion and inconvenience.
Primary care teams focused on cardiometabolic conditions have nurse navigation, coaching, and case management functions. In our current system most nurse navigators, case managers, and coaches work for the health plan. There is huge variation from one primary care provider to another in their medical and lifestyle management of these patients even within usual care practices. The case managers, navigators, and coaches at the health plan introduce still more variation. They don’t know how the provider approaches these problems. Is it any wonder that patients are completely confused and don’t know what to do? They are getting mixed messages from multiple providers and support staff. Protocols and systems get your team on the same page. Your primary care team can dramatically improve patient convenience and reduce patient confusion.
The main reason patients must go to the primary care office to manage blood pressure, cholesterol, and diabetes is because providers are paid to sit face-to-face with a patient and write a note describing the visit. That is what they are paid for and that makes visits to the office necessary. Home pressure measurements are more accurate than office measurements. Blood glucose can easily be measured and managed at home. Bluetooth devices can automatically transmit results to the primary care team and adjustments to treatment can be made over the phone. Lab work can be ordered over the phone. Some visits are still needed to establish relationship and trust, but we can have more effective and convenient care now. Telemedicine coordinated with the practice team can provide even more access and convenience. Information technology to support providing care while measuring clinical and financial outcomes rounds out the approach. Most visits can be done remotely. No more traveling dozens of miles and sitting in a waiting room two hours for a seven minute visit need occur. Just imagine the impact on patient and payer satisfaction. Disadvantaged and rural patients who face transportation challenges especially benefit.
Primary care providers have simple goals. They just want to provide excellent care and be reasonably rewarded for their good work. The current system is a barrier to those goals. If we make the changes above and support it with an appropriate payment model, they and other team members can find more satisfaction in their work. We can’t keep doing the same thing and expect a different result. These practical changes will be needed to produce the quadruple aim in your practice consistently.