Fragmentation of Care

At the physician level, fragmentation manifests as practices that do not contemplate the full scope of patient needs, but rather addresses immediatelypresented conditions in isolation. The “fragmentation” in this sense is the splintering of the physician's and her coworkers’ attention in a primary care setting rather than pursuing a practice of “whole person” care. “Whole person” care in the primary care setting entails interdisciplinary practice incorporating insights from the patient, family, and community, including an understanding that supporting wellness requires understanding social as well as medical needs.Reference Ellner and Phillips16 Primary Care reform is best addressed by empowering physicians to transform primary care practice into a hub of a patient-centered delivery system. Wellorganized patient-centered primary care gather and analyze historical and ongoing patient information to foster collaborative care and prevent inconstant treatment, and it can drive an intentional, evidence-based method of achieving patient goals.Reference Wise17

Primary care settings are the natural home for coordination so conceived, as they are the point of entry for most patients to courses of care. Integrative care models, to be successful, must also attend to the professional satisfaction of practitioners. A byproduct of the fragmented system has been a rising level of frustration among physicians who bridle at increasingly narrow ranges of practice and pressure to achieve quantity even at the cost of quality of care.Reference Jackson18 Research into optimal practice design is ongoing; however, empowering primary care practices through some of the emerging practice models to engage in the evaluation and management of patients over a course of treatment is likely to both improve patient care and permit more satisfying use of professional skills and knowledge.19

Social Needs and Social Determinants in Physician Practice

It is now well-known that unsatisfactory health outcomes and persistent health inequities in the U.S. system are traceable in large part to social determinants of health. Those determinants include structural and social conditions including access to secure housing, sound education, nutritious food and exposure to racism, poverty, and crime. A necessary concomitant to the goals of patient-centered primary care is attention to social determinants.Reference DeVoe20 The incorporation of patients’ social needs into physician practices needs to be approached with care. Enthusiasm for making social determinants of health a focus of primary care practice must be tempered; integrated care can knock down silos, but specialization must be respected. While physicians should evaluate patients for social needs that impair health, physicians are not, nor should they be, in charge of the remediation of all inequitable effects of the social determinants of health.Reference Green and Zook21

Within the competency of physician practices, however, much can be done to include attention to patient's social needs. Physicians can include assessments for social needs in clinical protocols. They can use screening guidelines in initial patient interviews. They can collocate or forge close relationships with key social service providers and expand the notion of “interdisciplinary teams” to include, for example, lawyers, vocational counselors, and housing specialists as circumstances require. They can also include home visiting services in their practice portfolios.Reference Garg22 The expansion of practice to include these services can improve patient care and permit more satisfying practice experience. Such expansion of services is not well-supported by traditional payment practices. Reformed payment theory must follow practice reform.

Payment Reforms Supporting Integrated Primary Care

As is described above, delivery reform is only one-half of the systemic reform puzzle — payment reform is the other half. As reforms in insurance coverage and design proceed, it will be important to recognize the transformation of our medical insurance system to a health insurance system. Payment reform is necessary to shape and support health systems reform, including reform of primary care. The mechanisms of payment must follow the logic of care delivery reform. Fragmented fee-for-service must give way to payment that supports and fosters more integrated primary care. Value-based payments to support the additional cost of integrated, patient-centered care, and to support date analytic capabilities to gather and report quality and outcomes data will help to align payment and delivery reform for physicians. The costs of robust patient centered care include the use of expanded health records and community resources data bases to both follow patients effectively and maintain current and detailed inventories of social referral sources.23 The income from value-based payment methods can be sufficiently flexible to permit partnerships with a variety of social service partners to address patients’ social needs while providing appropriate incentives for practices to provide high-quality, comprehensive services.

Financial flexibility coupled with well-designed quality and outcomes measures are critical to efforts to implement integrative primary care. The needs of patients with complex medical and social deficits cannot be reduced to a reimbursement formula, and per-service payment is therefore inadequate. Quality bonuses, partial capitation, full capitation, and other forms of alternative payment recognize this uncertainty, and leave to the practice the individual patient assessments of needs and care responses. At the same time, practices must participate in the broader system's goals of improving outcomes within a sustainable cost structure, and suitable measures of quality and outcomes is therefore vital.Reference Blumenthal and Abrams24 Primary care practices’ leadership is essential to achieve health reform goals, and that requires support as well as clear, system- wide shared goals.

We’re Not Alone: The Lessons from Europe

The U.S. may be an outlier in terms of national health costs, but it is far from alone in facing inflationary pressures in the delivery of care. Although starting at a lower base, many other nations have long been concerned about the seemingly inexorable growth in health budgets.25 European systems are heterogeneous in structure, performance, and outcomes.26 Cost containment measures sometimes include tools pioneered in the U.S.,Reference Busse27 and considerations of means to moderate cost and improve quality at the patient level are quite independent of the structure of the national health system.

Research into improvements in health care in Europe have, as in the U.S., addressed the need for integrated care. As in the U.S. researchers have recognized an interest in reducing payer fragmentation, providing increased agency for practitioners, increasing the use of data to coordinate care, and implementing methods to ensure that practices further system goals of improved quality and cost containment.28 Many European countries employ supplemental payments to primary care providers for care coordination, value-based payments such as pay-for-performance, and alternative payment methods such as bundled payments.Reference Tsiachristas29

Focus on tools that empower physicians to integrate care while setting parameters for outcomes and quality are, then, on the agenda in diverse European health systems. This observation supports the assertion that similar mechanisms are appropriately examined in the U.S., and that their appropriate implementation will be important regardless of the future shape of the U.S. overall health finance and delivery system.