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INTRODUCTION

The 21st century began with some very exciting changes for primary care and specifically for family medicine. These changes are continuing to accelerate, heralding a bright future for the specialty. In this chapter we will discuss why a new model of primary care is essential; describe past, current, and future efforts for redesigning primary care with a focus on the patient-centered medical home (PCMH); and conclude with a discussion of how to transform both medical practices and the nation’s healthcare delivery system to take full advantage of the PCMH’s potential to improve the quality of, and access to, affordable care that enhances the well-being of everyone in this country.

THE NEED FOR CHANGE

The objective of any system of healthcare should be to improve the lives of the patients it serves, in terms of both the quality and the length of those lives, to create an environment in which people feel better, avoid preventable medical problems, ameliorate the effects of existing disease, and enjoy the lives they have as fully as possible.

Currently in the United States there are too many people who do not have adequate access to care, receive care that is of less than optimal quality, and obtain care that costs too much and has significant disparities in its provision (Institute of Medicine 2001). We need to do things differently because we know that there is a better way; a way that is based on solid scientific fact, which builds on the good of our current system and that is fair to all.

We must change from rewarding doing things to people, and create incentives to do things for people, from paying to do a task to paying for thinking about the task. Is a given procedure the most appropriate one for this individual at this particular time, if ever?

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Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press; 2001.  [PubMed: NBK222274]   [PubMed: 3199556]

HEALTH SYSTEM REFORM

Past Attempts

A. Managed Care

In the early 1990s the idea of “managed care” was introduced into the United States, primarily as a way to increase profits and control costs by the insurance industry. This was popularly known as the “gatekeeper” system. Patients were required to visit a primary care provider (even though many subspecialists functioned in this role) who was approved by their insurance carrier to provide services under a particular plan as an entry point for any further access to the healthcare system. Payment was made to the physician on a capitated basis; that is, a fixed amount was paid to the physician for each member of that insurance plan who designated that individual as his or her primary care physician. The payment was the same ...

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