The Family Medicine Education Consortium is an organization promoting direct primary care. They sent along this article detailing the failure of primary care management in British Columbia, Canada and asked for comments. The short version is, you can’t take a system with misguided incentives and manage, or bribe, for better results as a last resort.
Name (with credentials): J. Timothy Ames, MD
Organization: J. Timothy Ames, MD PC
Comments: I agree with this quote from the article:
“This time around, before spending billions, we need to agree on what success looks like, and monitor progress from the start.”
British Columbia put a relatively small amount of money on the table for primary care physicians in order to encourage them to do chronic disease management, then simply hoped that things would get better. The physicians had little guidance, and less motivation, to achieve the ill-defined goal of “better” health care.
I disagree with this quote from the article:
“Most importantly, we need to broaden the team that is involved in choosing reforms to include health authorities, nurses and other service providers — and patients. All are necessary to delivering primary care and so all should have a hand in shaping it.”
This is a formula for talking the problem to death but not improving anything. The government needs to resist the temptation to over-engineer solutions with inputs from dozens of stakeholders. They should simply define an easily measurable goal, e.g., decrease the rate of hospitalization for a cohort of 10,000 patients. They should decide who are the best people to direct efforts to achieve this goal, e.g., physicians. They should pay for what they want, e.g., “We will deem you this patient’s primary care physician, and we will pay you $25 for every day that this patient is not in the hospital.” The government should then walk away and see what happens. The physicians receiving the money will then figure out what resources they need to assemble to achieve the goal, whether it is nurses and pharmacists, or cooks and housecleaning staff.
We have to admit that we don’t know how to achieve population-wide healthcare goals, and that the attempts to do so by “building teams” guided by “smart management” and “seeking diverse opinions” have been reflections of bureaucratic prejudices about problem-solving, and have been wretched failures. We need to decide what we want from public healthcare, arrange to pay for what we want, stop paying for what we don’t want, and prepare to be surprised by what naturally evolves.