Improving Primary Care

The staff of the American Medical Quality System would obtain information from clinics, purchasing cooperatives, institutes, and professional societies to determine benchmarks and best practices that are in current use for primary care practices. It would evaluate their effectiveness and would also fund the research necessary to develop new benchmarks and best processes and test them in its participating high-performance clinics.

Among the best processes that it would investigate, for example are:

• When a primary care doctor should refer to a specialist such as a cardiologist, nephrologist, surgeon or neurologist.
• What are the optimal means of managing the specific medical condition of patients with heart failure, heart disease, lung failure, diabetes, cancer, and other common conditions?
• How should management vary among patients with different economic and educational levels and ethnicity?
• What should be a standard imaging and diagnostic work-up for a range of medical conditions?

Among the benchmarks of quality that it would develop are:

• What is the irreducible number of potentially preventable emergency room and hospital admissions for patients with a specific medical condition?
• What target blood pressure, cholesterol, and blood glucose levels are achievable among patients who vary in educational status and health condition?

The American Medical Quality System would provide the start-up capital to clinics that choose to participate in its payment experiments. Necessary start-up resources would be, for example, information technology and clinic-based nurse-collaborators. The objective would be for practices to pay back the start-up capital over a period of several years when the savings from efficient practice were realized.

The AMQS would also negotiate payment rates and methods of payment among a clinic’s public and private payers and accept payments from them and distribute to providers. This function might be necessary to prevent anti-trust violations that could occur with open sharing of proprietary information among payers. A single entity handling payments would also reduce clinic billing and collection overhead. It would be simpler to bill one payer than a multitude of payers each requiring different forms and documentation.

From the primary care doctor’s point of view, what would be required to participate is the efficient practice of medicine, not the business negotiations required to get there. The AMQS would learn from its participating clinics and teach the methods to others.

Medical Education and Workforce

The AMQS would work with the American Association of Medical Colleges, with professional societies, and with directors of medical training programs to make necessary changes in the training of primary care doctors for an expanded role in American medicine.

The AMQS would communicate to students of American medical schools that it is a national priority to resurrect primary care and that anyone entering the specialty could expect a competitive income. The objective would be to increase the demand for and rigor of training in primary care in order to increase the size and the capability of the primary care work force.

The combination of increased income for practicing primary care and increased satisfaction of practice would, I believe, result in many graduates of American medical schools choosing primary care over specialty care.