Time to Do the Right Thing: End Fee-for-Service for Primary Care

A shifting terrain: Understanding the perspectives of walk-in physicians on their roles amid worsening primary care access in Ontario, Canada

BACKGROUND

High-quality primary care is associated with better health outcomes and more efficient and equitable health system performance. However, the rate of primary care attachment is falling, and timely access to primary care is worsening, driving many patients to use walk-in clinics for their comprehensive primary care needs. This study sought to explore the experiences and perceived roles and responsibilities of walk-in physicians in this current climate. Methods: Qualitative interviews were conducted with nineteen physicians currently providing walk-in care in Ontario, Canada between May and December 2022.

RESULTS

Limited capacity for continuity and comprehensiveness of care were identified as major sources of professional tension for walk-in physicians. Divergent perspectives on their roles were anchored in how physicians viewed their professional identity. Some saw providing continuous and comprehensive care as an infringement on their professional role; others saw their professional role as more flexible and responsive to population needs. Regardless of their professional identity, participants reported feeling ill-equipped to manage the swell of unattached patients, citing a lack of time, resources, connectivity to the system, and remuneration flexibility. Conclusions: As practice demands of walk-in clinics change, an evolution in the professional roles and responsibilities of walk-in physicians follows. However, the resources, structure, and incentives of walk-in care have not evolved to reflect this, leaving physicians to set their own professional boundaries with patients. This results in increasing variations in care and confusion across the primary care sector around who is responsible for what, when, and how.

Association between natural hazards and postnatal care among the neonates in India: a step towards full coverage using geospatial approach

BACKGROUND

Postnatal care is crucial to prevent the child mortality. Despite the improvement in the PNC coverage for the neonates, it is still far away from the universal health coverage. Along with, some specific regions mostly are natural hazard prone areas of India show very under coverage of PNC for the neonates. Considering the substantial spatial variation of PNC coverage and natural hazard prevalence, present study aimed to examine spatial variation of PNC coverage and its association with natural hazard at the district level.

METHODS

The cross-sectional exploratory study utilized National Family Health Survey, 2019-21, which included 1,76,843 children using multistage stratified sampling method to examine postnatal care within 42 days for neonates born within five years prior to the survey. Additionally, the study utilized Vulnerability Atlas of India,2019 maps to categorize regions into hazardous (flood, earthquake, and landslide) and non-hazardous areas. Spatial univariate and bivariate analyses, logistic and geographically weighted regressions were conducted using ArcGIS Pro, GeoDa, and Stata 16.0 software to identify associations between PNC coverage, hazard exposure, and spatial variation.

RESULTS

The univariate spatial analysis showed some specific regions such as north, east, and north-east region of India had a high concentration of natural hazard and low access of PNC coverage. Bivariate analysis also showed that PNC coverage was low in flood (75.9%), earthquake (68.3%), and landslide (80.6%) effected areas. Compared to the national PNC coverage (81.1%), all these natural hazards effected areas showed low coverage. Further, logic regression showed that these hazard prone areas were less (OR:0.85 for flood, 0.77 for earthquake, and 0.77 for landslide) likely to get PNC coverage than their counterparts. LISA cluster maps significantly showed low PNC and high disaster concentration in these disaster-prone areas. Geographic weighted regression results also showed similar result.

CONCLUSIONS

The present study elucidates notable heterogeneity in the coverage of postnatal care (PNC) services, with lower concentrations observed in disaster-prone areas. In order to enhance the accessibility and quality of PNC services in these areas, targeted interventions such as the deployment of mobile health services and fortification of health systems are recommended.

QUiC Clinics in the Central Texas Market: Value-Based Primary Care in Military Medicine

INTRODUCTION

For the past 16 years, Military Health System primary care providers have been incentivized to pursue work in a fee-for-service (FFS) model. The system values documentation of productivity to earn as many relative value units as possible. The result is densely packed clinic schedules that often lack the space or flexibility to accommodate patients when sick. Leakage ensues. Furthermore, prevention and patient experience are not directly incentivized.

METHODS

The Central Texas Market's Accountable Care Organization reformed incentives in its #5 FFS-designed community-based medical homes to value outcomes over productivity. The resulting quality, urgent, internet, and phone care (QUiC) clinics are value-based and, therefore, better structured to achieve the Quad aim (better care, better health/readiness, and low cost). Forsaking deeply ingrained FFS practices, QUiC clinics funnel all routine (information-sharing) appointments into efficient internet or phone appointments. With the time freed by managing common needs in short bursts, QUiC clinics see sick patients with no notice (urgent care). They also focus on prevention and patient experience. We measured the effectiveness of the QUiC clinics in the value-based metrics of (1) patient experience, (2) Healthcare Effectiveness Data and Information Set measures of quality and prevention. (3) access-to-care, (4) leakage, and (5) enrollment.

RESULTS

Over a 19 month period, the five community-based medical homes improved significantly in all areas. Specifically, measures of patient satisfaction improved from the mid-80s percent satisfied to the mid-90s percent satisfied. Healthcare Effectiveness Data and Information Set measures increased from average compared to national benchmarks (<50th percentile to 75th percentile) to the 90th percentile in four of five measures of quality and the 75th percentile in the remaining measure. Access to care for routine appointments decreased from 15.4 days to the third next available appointment to 2.8 days. Leakage decreased from 12.2% to 9.6%. These successes were attained without cost or significant reductions in patient enrollments. In changing workflows, the market became the #1 user of virtual video visits in the DOD.

CONCLUSIONS

This performance improvement project proved the concept that a military market can vastly improve value-based primary care outcomes at no cost and within multiple community-based clinics.

An exploration of barriers and enablers to the conduct and application of research among complementary and alternative medicine stakeholders in Australia and New Zealand: A qualitative descriptive study

BACKGROUND

Most studies examining complementary and alternative medicine (CAM) stakeholder engagement with evidence-based practice have relied on quantitative research methods, which often fail to capture the nuances of this phenomena. Using qualitative methods, this study aimed to explore the experiences of CAM stakeholders regarding the barriers and enablers to the conduct and application of research.

METHODS

This research was guided by a qualitative descriptive framework. CAM practitioners and researchers of multiple CAM disciplines from across Australia and New Zealand were invited to share their personal perspectives of the study phenomena. Semi-structured interviews were conducted via Zoom, which were audio-recorded and transcribed verbatim. Rigour strategies were applied to ensure the credibility of results. The transcript was analysed using thematic analysis.

RESULTS

CAM stakeholders identified an array of barriers and enablers to the conduct and application of research within their disciplines. The barriers and enablers that emerged were found to be inter-connected with two similar constructs: capacity and culture. Captured within the construct of capacity were five themes-lack of resources, inadequate governance/leadership, lack of competency, bias directed from outside and within CAM, and lack of time for research. Within the construct of culture were two themes-intrinsic perceptions in CAM, and lack of communication within and outside CAM.

CONCLUSIONS

Promoting evidence-based practice and engaging with research in CAM continues to face challenges. This study, for the first time, has highlighted the multitude of interlinked barriers that confront CAM stakeholders when engaging with research. These findings highlight the need for a concerted and targeted approach to tackle these challenges.

Quality of primary health care in China: challenges and recommendations

China has substantially increased financial investment and introduced favourable policies for strengthening its primary health care system with core responsibilities in preventing and managing chronic diseases such as hypertension and emerging infectious diseases such as coronavirus disease 2019 (COVID-19). However, widespread gaps in the quality of primary health care still exist. In this Review, we aim to identify the causes for this poor quality, and provide policy recommendations. System challenges include: the suboptimal education and training of primary health-care practitioners, a fee-for-service payment system that incentivises testing and treatments over prevention, fragmentation of clinical care and public health service, and insufficient continuity of care throughout the entire health-care system. The following recommendations merit consideration: (1) enhancement of the quality of training for primary health-care physicians, (2) establishment of performance accountability to incentivise high-quality and high-value care; (3) integration of clinical care with the basic public health services, and (4) strengthening of the coordination between primary health-care institutions and hospitals. Additionally, China should consider modernising its primary health-care system through the establishment of a learning health system built on digital data and innovative technologies.