By Paul Grundy, Kay R. Hagan, Jennie Chin Hansen, and Kevin Grumbach

The Multi-Stakeholder MovementFor Primary Care RenewalAnd Reform

ABSTRACT A multi-stakeholder movement for primary care renewal andreform has emerged in the United States, out of recognition that theachievement of an efficient, effective, and sustainable health systemrequires a vibrant primary care sector. We describe the case for reformfrom the perspective of private purchasers, government, consumers, andclinicians; the principles around which these stakeholders have coalesced;the groundswell of primary care reform initiatives taking place across thecountry; and the prospects for this coalition to reshape the character ofU.S. health care on a stronger foundation of primary care.

The nation’s approach to deliveringhealth care is inefficient, ineffec-tive, and unsustainable. For indi-vidual patients seeking care aswell as for large companies trying

to stay competitive and create jobs in the UnitedStates, health care costs too much and offers toolittle value in return. Government and private-sector purchasers of health care are demandingsystems of payment and practice reorganiza-tion that promote the comprehensive, patient-focused primary care that beneficiaries and em-ployees require. They are launchingprimary careinitiatives across the nation to achieve this goal,often with consumers as active partners. Theyare finding primary care clinicians receptive tothe challenge of creating high-performancemodels of primary care.

The Case For Primary Care RenewalAnd ReformPrivate Purchaser Perspective Largeemploy-ers seek to buy comprehensive, coordinated,integrated, accessible health care for their em-ployees. Instead, what they tend to find is epi-sodic, uncoordinated, fragmented, specialty-focused care that seeks to reap rewards fromcostly, specialized medical procedures.1–3

According to Jennifer Baron and AlexanderMuggah of the Institute for Strategy and Com-petitiveness at Harvard Business School, “Em-ployees and their families who lack effectiveprimary care, prevention, and chronic diseasemanagement often cannot be productive mem-bers of the workforce.”4 Avoidable hospital ad-missions for asthma and diabetes complicationsare more than two times more prevalent in theUnited States than the average among the thirtycountries in the Organization for Economic Co-operation and Development (OECD). Thesehigher rates of admission are not explained bya higher underlying prevalence of asthma anddiabetes in the United States. What’s more, apersonwith diabetes is twice as likely to undergoa lower-extremity amputation in the UnitedStates as is a diabetic in other developed nations.The OECD concludes, “The United States doesnot do well in preventing costly hospital admis-sions for chronic conditions, such as asthma orcomplications from diabetes, which should nor-mally be managed through proper primarycare.”5

Large employers are becoming vocal in artic-ulating their desire for a more primary care–ori-ented model of care. J. Randall MacDonald,senior vice president for human resources ofthe IBM Corporation, was invited to testify at

doi: 10.1377/hlthaff.2010.0084HEALTH AFFAIRS 29,NO. 5 (2010): –©2010 Project HOPE—The People-to-People HealthFoundation, Inc.

Paul Grundy (pgrundy@us.ibm.com) is global director ofhealthcare transformation atIBM in Somers, New York.

Kay R. Hagan is a DemocraticU.S. senator representingNorth Carolina.

Jennie Chin Hansen is theoutgoing president of AARPand the incoming chiefexecutive officer of theAmerican Geriatrics Society,both in Washington, D.C.

Kevin Grumbach is professorand chair of the Departmentof Family and CommunityMedicine, University ofCalifornia, San Francisco.

MAY 2010 29:5 HEALTH AFFAIRS 1

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the29April 2009HouseCommittee onWays andMeans hearing, “Health Reform in the 21st Cen-tury.” IBM covers more than 450,000 employ-ees, dependents, and retirees in the UnitedStates, at a cost of $1.3 billion in 2008.The committee askedMacDonaldwhat he con-

sidered the single most important repair to thehealth care system. He replied, “Strengthen pri-mary care—transform it and pay differently us-ing a model like the patient-centered medicalhome.” When MacDonald was asked to identifythe next most important issue, he answered, “Ifyou don’t fix the first issue and do not havea foundation of powerful primary care, thenyou can do nothing else.…Primary care is foun-dational, but we need it to be smarter, withthe tools and payment reform to allow it to bebetter integrated, continuous, coordinated, andcomprehensive.”6

IBM has been a leader among U.S. corpora-tions in demonstrating its willingness to investin revitalization of primary care. It has pilotednew approaches to supporting and paying forprimary care with its contracting health plans;made primary care visits and preventive servicesfree of any cost sharing under its self-insuredplans; and spearheaded a national coalition ofpurchasers, provider organizations, and con-sumergroups in the formof thePatient-CenteredPrimary Care Collaborative.Government Perspective Public purchasers,

contending with the same issues confrontingprivate purchasers, are also leading initiativesto invest in and redesign primary care. The na-tion’s lagging clinical outcomes andhigh rates ofavoidable hospitalizations for patients withchronic conditions are particularly salient topublic purchasers. This is the case because pro-grams such as Medicare and Medicaid cover adisproportionate share of the population withchronic illnesses.7

▸▸MEDICARE: Medicare policies have effectsthat extend well beyond beneficiaries. BecauseMedicare is the largest single buyer of care,manycompanies, such as IBM, buy health care thesame way Medicare does. Private payers oftenbase their physician fee schedules on the Medi-care resource-based relative value scale, therebyextending the widening gap in Medicare com-pensation for primary care and specialty serv-ices. Medicare is also the dominant source offunds for residency training, providing nearly$9 billion annually to hospitals for graduatemedical education with few requirements aboutthe distribution of funded residency positionsbetween primary care and specialty fields.▸▸FEDERAL GOVERNMENT: One of the few

areas of bipartisan agreement in health reformhas been to place more emphasis on primary

care. Sen. Orrin Hatch (R-UT), at a Senate Fi-nance Committee hearing in April 2009, stated,“The U.S. is first in providing rescue care, butthis care has little or no impact on the generalpopulation.We must put more focus on primarycare and preventive medicine. How do we trans-form the system to do this?”8 President BarackObama shared similar concerns at aWhiteHouseforum, declaring, “We’re not producing enoughprimary care physicians.”9 Building an effectiveprimary care workforce subsequently becameone of the key recommendations for healthreform from former Senate Majority LeadersHoward Baker, Bob Dole, and Tom Daschle.10

In drafting health reform bills in 2009, legis-lators in theHouse and Senate included a varietyof measures to strengthen primary care, such asincreases in Medicare and Medicaid fees for pri-mary care, medical home demonstration pro-grams, increased funding for National HealthService Corps primary care scholarships andloan repayment, incentives for recruiting stu-dents into rural medicine, and a primary careextension program to support practice improve-ment.With the enactment of health reform legis-lation in March 2010, those steps now have theforce of law behind them.▸▸STATE GOVERNMENTS: State governments

also have been spearheading innovations in pri-mary care. A leading state-level model is Com-munity Care of North Carolina. This programlinks Medicaid and Children’s Health InsuranceProgram (CHIP) enrollees to community-basedprimary care medical homes; provides technicalassistance to improve chronic care; and employsnurses,mental healthworkers, pharmacists, andother health professionals to collaborate in casemanagement for high-risk patients. In additionto operating on fee-for-service reimbursement,the program pays primary care practices a permember per month care coordination fee foreach patient registered with the practice, inthe amount of $2.50 per month for childrenand $5.00 for aged anddisabled patients. Startedas a pilot program in 1998, Community Care ofNorth Carolina now involves more than 1,300community-based practices, 4,500 primary careclinicians, and 970,558 enrollees throughoutNorth Carolina. Evaluations have documentedthat this model has improved quality and savedthe state $400 million in 2008.11,12

Consumer Perspective Consumers experi-ence frustration and adverse health outcomesas a result of fragmentation of care and difficultygaining access to primary care. “Where Have Allthe Doctors Gone?” queried a headline in the2 September 2008 issue of AARP Today, relatingtheplight of seniors unable to find aprimary carephysician.13 A Harris poll from that same month

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found that 67 percent of U.S. adults rated asextremely or very important “the ability to havea relationship with a doctor who takes a whole-person approach to patient care (social, mentaland physical care) and who provides care for alllevels of health.”14 More than half, or 56 percent,reported “difficulty navigating the healthcaresystem for themselves and/or their familymembers.”Testifying at a May 2009 Senate Finance Com-

mittee hearing, AARP president Jennie ChinHansen stated, “Effective practice models thatemphasize, encourage, and improve primarycare should be expanded and incentives shouldbe created to encourage individuals to practice inprimary care. …Strengthening the primary careworkforce is an essential part of ensuring theprovision of quality affordable health care forall.”15

There is an urgent need for solutions as accessissues become more visible. More than thirtyconsumer organizations, including AARP, theAFL-CIO, Consumers Union, Families USA, theNAACP, and the National Partnership forWomen andFamilies, have endorsed a statementof principles, titled “TheMedical Home from theConsumer’s Perspective.”16

Primary Care Clinician Perspective Pri-mary care clinicians often feel undervaluedand overwhelmed. They experience a paradox:Primary care is more important than ever in thetwenty-first century, but the approach to deliv-ering it is stuck in the early twentieth century. Agrowing array of evidence-based interventionscanbeapplied inprimary care settings topreventdisease, manage chronic illness, and alleviatesuffering. At the same time, the coordinatingrole of primary care has taken on added valuein proportion to the increasing complexity ofmodern health care. And health informationtechnology (IT) makes possible new ways tocommunicate with patients over space and time,integrate care, andmeasure andmanage the careof a defined population of patients.Despite these advances, investment in primary

care has lagged in the United States. This inat-tention is seen not only in the widening gap inearnings between primary care physicians andspecialists, but also in the undercapitalization ofprimary care practices. A 2009 CommonwealthFund survey found that fewer than half of pri-mary care physicians in the United States had anelectronic health record in their offices, com-pared withmore than 90 percent of primary carephysicians in most European nations surveyed.U.S. primary care physicianswere alsomuch lesslikely than their European counterparts to havepractice teams that included nonphysicians tocollaborate on chronic care management.17

The Commonwealth Fund survey also impli-cates U.S. primary care clinicians for not havingtaken more ownership of improving aspects ofcare more directly under their control. Only29 percent of U.S. primary care physicians re-ported that they had after-hours arrangementsfor their patients “to see a doctor or nurse with-out going to the [emergency room].”17 TheUnited States ranked the lowest among theeleven nations surveyed on this metric.Primary care physician organizations have en-

dorsed getting their ownmedical house in order.The American Academy of Family Physicians’Future of Family Medicine project called fornew models of practice.18 The academy investedresources to develop the TransforMED center tofacilitate and provide technical assistance for anational demonstrationproject of practice trans-formation. Other primary care physician organ-izations have mounted their own primary careimprovement programs.

Building A Coalition For RenewalAnd ReformPurchasers, consumers, and clinicians are form-ing a coalition to renewand reformprimary care.They are motivated by the shared beliefs thatprimary care is vital to a well-functioning healthsystem and that the traditional focus of primarycare—care that is accessible, comprehensive,and integrated and that fosters a healing rela-tionship over time in the context of family andcommunity—remains just as relevant today forachieving high-value health care as when firstarticulated decades ago.19,20

Need For Practice Redesign The call for re-form, and not simply renewal, derives from thebelief that the form fordelivering the traditional,core primary care functions of first-contactaccessibility, comprehensiveness, coordination,and continuitymust be retooled in the context oftwenty-first-century health care. Dysfunctionalpractice models must be redesigned to bettermeet the needs of patients and primary care cli-nicians alike.For example, primary care practices must

adopt new methods to promote access, such assame-day “openaccess” appointment systems, aswell asWebportals for secure e-mailing and com-munication of laboratory results. The achieve-ment of comprehensive, coordinated care forpatients with chronic illnesses requires team-based models of primary care that can pro-actively intervene to avert deterioration of con-ditions such as heart failure and asthma, activatepatients in the self-managementof theirdiabetesand other chronic illnesses, and use electronicregistries to track key clinical metrics.21

MAY 2010 29:5 HEALTH AFFAIRS 3

New Levels Of Agreement Renewal and re-form of primary care in the United Statesrequires a new compact among purchasers, con-sumers, and clinicians. Purchasers and consum-ers must value primary care, invest resources torevitalize the primary care infrastructure, sup-port innovative models of care, and providegreater incentives for careers in primary care.In return, primary care clinicians must acceptgreater accountability for performance stan-dards, be receptive to innovation and practiceredesign, and embrace a more patient-centeredapproach.22 Terms such as patient-centered medi-cal home and advanced primary care models havecome intouse to convey this spirit of renewal andreform of primary care.23

Shared Vision Thegoal of renewal and reformappear to be in sight, thanks to a shared visionamong stakeholders for the future of primarycare, and an unprecedentedwillingness of stake-holders to work together. The catalyst for thispartnership has been the Patient-Centered Pri-maryCareCollaborative, a coalitionofmore than600 organizations, including large employerssuch as IBM, Boeing, GlaxoSmithKline, Good-year, and Whirlpool; consumer groups; unions;primary care clinician organizations; and othergroups, with a mission to “advance the patient-centered medical home.”1,24

One of the collaborative’s first major achieve-ments was to overcome the historical divisionsbetween primary care specialty groups. In 2007the American Academy of Family Physicians,American Academy of Pediatrics, American Col-lege of Physicians, and American OsteopathicAssociation, collectively representing aboutone-third of U.S. physicians, agreed on a set ofjoint principles of the patient-centered medicalhome.25

The collaborative has subsequently workedto make language in the joint principles moreinclusive of nurse practitioners, physician assist-ants, and other nonphysician clinicians, agree-ing to support nurse practitioner–led patient-centered medical home pilots that conform tolegal and clinical standards.26

Through a combination of conferences, re-ports and brochures, technical assistance, advo-cacy, and coalition building, the collaborativehas played a critical role in advancing primarycare reform. The diversity of its member organ-izations gives it a distinctive legitimacy and in-fluence. Its positions cannot be dismissed assimply those of self-interested professionalgroups, or as a one-sided attempt by purchasersandhealth plans to impose an unpopular organi-zational model on physicians and patients—thetype of criticism leveled atmanaged care reformsin the 1990s.

The Future Of Primary Care Is NowAcross the nation, examples can be found wherethe future is already here for primary care.Whole Child Pediatrics Xavier Savilla oper-

ates Whole Child Pediatrics near Tampa Bay,Florida, a solo practice providing services in En-glish and Spanish to patients insured by a varietyof health plans, including Medicaid. Savilla re-gards his patients and their families as equalpartners in his practice.Whole Child Pediatrics has an electronic

health record with a patient portal, and familiesreview themedical record at the end of each visit.Parents of children in the practice serve on anadvisory board for Whole Child Pediatrics. Chil-dren with asthma monitor their peak-flow testsat home in tandem with an Internet-based self-management program. In the past two years,only one of the asthmatics under Savilla’s carehas required hospitalization. Family ratings ofthe practice are exceptionally high.27

Redlands Family Practice In Southern Cal-ifornia, Redlands Family Practice focuses on pa-tients at the other end of the age spectrum. Thisprivate practice of three family physicians, aphysician assistant, a registered nurse, and fiveoffice staff was recently profiled inHealth Affairsas a “medical home run” for its ability to improvecare while lowering costs.28 Concentrating onenhanced care for elderly patients with chronicillnesses, the Redlands Family Practice modelincludes round-the-clock phone access, a team-oriented approach, proactive nursing outreach,and careful selection of specialists for referral.Medical Associates Clinic Of Dubuque In

Dubuque, Iowa, a group of general internistsworking in a 100-physician, multispecialtygroup practice has implemented an innovativeteam model that closely pairs physicians withregistered nurses and licensed practical nursesto create practice efficiencies, improve the qual-ity of physician-patient interaction, andpromotemore timely access to care.29,30

Eleventh Street Family Health ServicesEleventh Street Family Health Services, anurse-managed, full-service, open-access com-munity health center, serves residents of fourpublic housing developments and the surround-ing community. Through the practice’s combi-nation of “one-stop shopping” with state-of-theart disease management protocols, a predomi-nantly poor and minority urban population hasachieved improved hypertension and diabetescontrol.31

Group Health Cooperative Integrated deliv-ery systems are reengineering primary care on abroader scale. In2007GroupHealthCooperativeof Puget Soundpiloted an advancedprimary caremodel at one of its Seattle sites. It entailed hiring

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additional primary care physicians to reduce thenumber of patients cared for by each physician;lengthening the duration of in-person visits;using more planned telephone and e-mail en-counters; building more team-based chronicand preventive care; and promoting round-the-clock access using modalities such as electronichealth record patient portals. A twelve-month,controlled evaluation found that quality and pa-tient experiences improved, emergency depart-ment visits and hospitalizations for ambulatorycare–sensitive conditions decreased, and physi-cian and staff ratings of the work environmentimproved.32 GroupHealth is currently spreadingthis model to all twenty-six of its primary careclinics, serving 380,000 patients.Other Factors These examples represent the

innovators and early adopters of new models ofprimary care. For these types of models to be-come the norm, systematic action from payersandpurchasers is needed toprovide the financialincentives, resources, and technical support todrive large-scale transformation of primary care.Indeed, payers and purchasers appear to bemov-ing in this direction.More than thirty states havefollowed North Carolina’s lead in implementingadvancedprimary caremodels for theirMedicaidand CHIP programs.33

Private and public payers are beginning to col-laborate on regional, multipayer projects toreach a criticalmass of practices and themajorityof the patients in these practices.34 For example,in 2009 the Hudson Valley and Adirondack re-gions of New York embarked on major primarycare reform initiatives involving most privatehealth plans in each region and Medicaid andincludingmore than 700primary care clinicians.Health plans and the New York State govern-ment are supporting the implementation ofhealth IT in the participating practices and offer-ing enhanced care coordination payments topractices meeting National Committee for Qual-ityAssurance (NCQA)medical home recognitionstandards.35

National Health Reform With the enact-ment into law of comprehensive health reforminMarch2010, the federal government’s engage-ment in primary care renewal is likely to beintensified. The American Recovery and Rein-vestment Act (ARRA) of 2009 provided as muchas$29billion inhealth IT fundingby2016. It alsotargeted a substantial amount of these funds toassist primary care practices in purchasing elec-tronic health records and achieving meaningfuluse of this technology.In September 2009, Health and Human Serv-

ices Secretary Kathleen Sebelius announced thatstates could petition to have Medicare partici-pate in state-based, multipayer, primary care

demonstration programs.36 The Department ofDefense announced a policy in September 2009requiring implementation of the medical homeas a “comprehensive primary care model to im-prove patient satisfaction and outcomes”37 for allmembers of the military’s health care system.Community Health Centers Federally

funded community health centers have also beenmaking steady progress in practice redesign,supported in part by Health Resources and Serv-ices Administration (HRSA) initiatives such ashealth center chronic care collaboratives. InDecember 2009, President Obama committedfunds to support the next level of primary caretransformation at these health centers.38

Department Of Veterans AffairsOneof theleast-heralded “big wins” in primary care trans-formation has been the reorganization of theU.S. Department of Veterans Affairs (VA) sys-tem. Although there is widespread recognitionthat the VA has refashioned itself into a qualityleader, much less appreciated is the instrumen-tal role of primary care in this transformation.The VA continues to reorient its delivery modelaround primary care, investing in the primarycare workforce and ambulatory care facilitiesand supporting integrated care models with awell-functioning electronic health record.39

Challenges And OpportunitiesThe compelling case for primary care, the devel-opment of a coalition of diverse stakeholders toadvocate for primary care, the promising exam-ples of innovators implementing advancedmod-els of primary care, and the evidence thatpurchasers and payers are beginning to investin more-systematic transformation of primarycare all bode well for the renewal and reformof U.S. primary care. Will this movement betransformative, creating a renaissance in pri-mary care, or will it falter at the stage of earlyadopters and demonstrations?Need For More Resources One key driver of

sustained change will be the dedication of moreresources to primary care, to increase primarycare compensation and to support and rewardenhanced models of primary care. Concernsabout the high costs of health care in the UnitedStates are likely tomake this a zero-sumgame forthe most part. Many purchasers and payers ex-pect that there will be offsetting savings in otherhealth sectors for the additional investmentsmade in primary care. However, this expectationwill present political and policy challenges. Arecent Medicare fee schedule revision that mod-estly increased primary care fees and reducedfees for imaging and certain procedural servicesin cardiology and other fields was greeted

MAY 2010 29:5 HEALTH AFFAIRS 5

warmly by primary care specialty societies butwas roundly criticized by several specialty soci-eties. The recently enacted health reform legis-lation will also boost payment for primary careunder both Medicare and Medicaid. But howmuch further policy makers will push to revaluefees from specialty to primary care remains to bedetermined.Short-Term Savings In addition, many pub-

lic andprivate purchasers that have agreed topaymore for medical home pilot programs havedone so with the expectation that these pro-grams will yield a short-term return on invest-ment, in the form of reduced expenditures foremergency department visits and hospitaliza-tions. Although some of the early programs haveshown such favorable results,32,34 many primarycare advocatesbelieve that theeconomic benefitsof primary care accrue over the long term. Theysay that it is unrealistic to expect primary carereforms to yield short-term savings from year toyear in the face of the many inflationary pres-sures affecting the health system. There is worrythat purchasers’ enthusiasm for primary carereform will wane if short-term savings fail tomaterialize.Better Medical ‘Neighborhood’ There is

also concern that even the best medical homemight not achieve its promise of better healthcare value if located in amedical “neighborhood”of hospitals and other provider organizationsthat resist integration of care and responsiblestewardship of health care resources. In thatcase, primary care renewalmay need to be linked

to other reforms, such as accountable care or-ganizations, to reorient incentives and valuesacross all health care tiers.40

Questions also remain about whether wide-spread transformation can occur across thesmall, independent offices and clinics wheremost primary care is delivered in the UnitedStates.41,42 Currently, successful scaling-up ofnewmodels of primary care is largely happeningin integrated delivery systems. In nations withrobust primary care systems, single-payer or co-ordinated all-payer systems have provided ameans of implementing systematic reform ofprimary care, such as systemwide rollout of elec-tronic health records and payment reforms. Themore diverse payment and delivery systems inthe United States make implementing suchbroad transformation more difficult.Importance Of Primary Care Despite these

challenges, a consensus has emerged that pri-mary care is “too important to fail.”43 The goalof a more affordable, effective, equitable, andsustainable health system for the American peo-ple cannot be achieved without renewal and re-form of primary care. Talk about the importanceof primary care is hardly new in the UnitedStates, yet the nation’s health system has beenremarkably resistant to past efforts to reshape iton a solid foundation of primary care. Theunprecedented coalescing of diverse stakehold-ers around a forward-looking vision of revital-ized primary care augurs well for a far differentoutcome than in the past. ▪

NOTES

1 Sepulveda MJ, Bodenheimer T,Grundy P. Primary care: can it solveemployers’ health care dilemma?Health Aff (Millwood). 2008;27(1):151–8.

2 Galvin RS, Delbanco S. Between arock and a hard place: understand-ing the employer mind-set. HealthAff (Millwood). 2006;25(6):1548–55.

3 Williams G. Aggressive medical carecan lead to more pain with no gain.Consumer Reports. 2008;73(7):40–4.

4 Wolverson R, Nichols L, Van deWater PN, Baron JF, Muggah A,Miller T, et al. Squaring healthcarewith the economy [Internet]. Wash-ington (DC): Council on ForeignRelations; 2009 Dec 8 [cited 2010Apr 1]. Available from: http://www.cfr.org/publication/20909/squaring_healthcare_with_the_economy.html?breadcrumb=%2Fpublication%2Fpublication_list%3Ftype%3Dinterview

5 Organization for Economic Co-operation and Development. Ex-

pensive healthcare is not always thebest healthcare, says OECD’s Healthat a Glance [Internet]. Paris: OECD;2009 Aug [cited 2010 Jan 3]. Avail-able from: http://www.oecd.org/document/14/0,3343,en_2649_34487_44216846_1_1_1_1,00.html

6 MacDonald JR. Testimony before theHouse Committee on Ways andMeans [Internet].Washington (DC):House of Representatives; 2009 Apr[cited 2010 Apr 13]. Available from:http://waysandmeans.house.gov/hearings/Testimony.aspx?TID=2149

7 Bodenheimer T, Berry-Millett R.Follow the money—controllingexpenditures by improving care forpatients needing costly services. NEngl J Med. 2009;361(16):1521–3.

8 Senate Finance Committee.Reforming America’s health caredelivery system. Senate FinanceCommittee Roundtable. Washington(DC): U.S. Senate; 2009 Apr 21[cited 2010 Apr 13]. Available from:http://finance.senate.gov/hearings/hearing/?id=d85e499a-01ed-23b6-7c6e-a200e6bee498

9 Pear R. Shortage of doctors an ob-stacle to Obama goals. New YorkTimes. 2009 Apr 26.

10 Baker H, Daschle T, Dole B. Crossingour lines: working together to re-form the U.S. health care system[Internet]. Washington (DC): Bipar-tisan Policy Center; 2009 Jun [cited2010 Apr 1]. Available from: http://www.bipartisanpolicy.org/sites/default/files/6.17_Crossing%20Lines_0.pdf

11 Steiner BD, Denham AC, Askin E,Newton NP, Wroth T, Dobson LA.Community Care of North Carolina:improving care through communityhealth networks. Ann Fam Med.2008;6(4):361–7.

12 Mercer. Executive summary, 2008Community Care of North Carolinaevaluation [Internet]. Phoenix (AZ):Mercer; [cited 2010 Apr 1]. Availablefrom: http://www.communitycarenc.com/PDFDocs/Mercer%20ABD%20Report%20SFY08.pdf

13 Barry P. Where have all the doctorsgone? AARP Today. 2008 Sep 2.

14 Harris Interactive. Patient centered

Urgency Of Problem

6 HEALTH AFFAIRS MAY 2010 29:5

medical home election study [Inter-net]. Washington (DC): Patient-Centered Primary Care Collabora-tive; 2008 Sep 10 [cited 2010 Jan 3].Available from: http://www.pcpcc.net/files/Harris%20Poll%20Findings%20Summary.pdf

15 Hansen JC. Testimony: expandingcoverage in health care reform [In-ternet]. Washington (DC): AARP;2009 May 5 [cited 2010 Jan 8].Available from: http://www.aarp.org/makeadifference/advocacy/GovernmentWatch/HealthCare/articles/testimony_expanding_coverage_in_health_care_reform.html

16 National Partnership for Women andFamilies. Principles for patient andfamily centered care: the medicalhome from the consumer’s perspec-tive [Internet]. Washington (DC):National Partnership; 2009 Mar 30[cited 2010 Jan 8]. Available from:http://www.nationalpartnership.org/site/DocServer/Advocate_Toolkit-Consumer _Principles_3-30-09.pdf?docID=4821

17 Schoen C, Osborn R, Doty MM,Squires D, Peugh J, Applebaum S,et al. A survey of primary carephysicians in eleven countries,2009: perspectives on care, costs,and experiences. Health Aff (Mill-wood). 2009;28:w1171–83.

18 Future of Family Medicine ProjectLeadership Committee. The Futureof Family Medicine: a collaborativeproject of the family medicine com-munity. Ann Fam Med. 2004;Suppl 2:S3–32.

19 Institute of Medicine. Primary care:America’s health in a new era.Washington (DC): National Acad-emies Press; 1996.

20 Starfield B. Primary care. New York(NY): Oxford University Press; 1998.

21 Bodenheimer T, Grumbach K. Im-proving primary care: strategies andtools for a better practice. New York(NY): Lange Medical Books–McGraw-Hill; 2008.

22 Bodenheimer T. Primary care—will itsurvive? N Engl J Med. 2006;355(9):861–4.

23 Rittenhouse DR, Shortell SM. Thepatient-centered medical home: willit stand the test of health reform?JAMA. 2009;301:2038–40.

24 Patient-Centered Primary Care Col-laborative. Patient-Centered PrimaryCare Collaborative [Internet]. Wash-ington (DC): PCPCC; [cited 2010Apr 1]. Available from: http://www.pcpcc.net/files/PCPCCbrochure.pdf

25 American Academy of Family Physi-

cians, American Academy of Pediat-rics, American College of Physicians,American Osteopathic Association.Joint principles of the patient cen-tered medical home [Internet].Washington (DC): Patient-CenteredPrimary Care Collaborative; 2007Feb [cited 2010 Jan 8]. Availablefrom: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home

26 Ginsburg J, Taylor T, BarrMS. Nursepractitioners in primary care [In-ternet]. Policy Monograph. Phila-delphia (PA): American College ofPhysicians; 2009 [cited 2010 Apr 1].Available from: http://www.acponline.org/advocacy/where_we_stand/policy/np_pc.pdf

27 Sevilla XD. AAP Fellows help identifyquality measures for children’s care.AAP News. 2009;30(12):4.

28 Milstein A, Gilbertson E. Americanmedical home runs. Health Aff(Millwood). 2009;28(5):1317–26.

29 Sinsky CA. Improving office practice:working smarter, not harder. FamPract Manag. 2006;13(10):28–34.

30 Okie S. Innovation in primary care—staying one step ahead of burnout. NEngl J Med. 2008;359(22):2305–9.

31 Gerrity P. The Eleventh Street FamilyHealth Services, Drexel University[Internet]. Washington (DC):American Academy of Nursing;[cited 2010 Apr 1]. Available from:http://www.aannet.org/files/public/11thStreetFamilyHelthSvcs_template.pdf

32 Reid RJ, Fishman PA,Yu O, Ross TR,Tufano JT, Soman MP, et al. Apatient-centered medical homedemonstration: a prospective, quasi-experimental, before and afterevaluation. Am J Manag Care.2009;15(9):e71–87.

33 Kaye N, Takach M (National Acad-emy for State Health Policy; Port-land, ME). Building medical homesin state Medicaid and CHIP pro-grams [Internet]. p 114. New York(NY): Commonwealth Fund; 2009Jun 23 [cited 2010 Jan 3]. Availablefrom: http://www.idph.state.ia.us/hcr_committees/common/pdf/medical_home/090209_building_programs.pdf

34 Patient-Centered Primary Care Col-laborative. Proof in practice: a com-pilation of patient centered medicalhome pilot and demonstrationprojects [Internet]. Washington(DC): PCPCC; 2009 [cited 2010Jan 9]. Available from: http://www.pcpcc.net/files/PilotGuidePip_0.pdf

35 O’Brien M. Landmark health initia-tive announced in Adirondacks [In-ternet]. WTen News. 2009 Oct 13[cited 2010 Jan 3]. Available from:http://www.wten.com/Global/story.asp?S=11304947

36 White House [Internet].Washington(DC): White House. Press release,Secretary Sebelius announces Medi-care to join state-based healthcaredelivery system reform initiatives;2009 Sep 16 [cited 2010 Jan 3].Available from: http://www.hhs.gov/news/press/2009pres/09/20090916a.html

37 Office of the Assistant Secretary ofDefense. Policy memorandum, im-plementation of the “patient cen-tered medical home” model ofprimary care in MTFs [Internet].Washington (DC): Department ofDefense; 2009 Sep 18 [cited 2010Jan 3]. Available from: http://www.bethesda.med.navy.mil/patient/health_care/medical_services/internal_medicine/PCMH%20Policy%20Memo%20-%20signed.pdf

38 White House [Internet].Washington(DC): White House. Press release,Remarks by the president on com-munity health centers; 2009 Dec 9[cited 2010 Jan 3]. Available from:http://www.whitehouse.gov/the-press-office/remarks-president-community-health-centers

39 Shear J. Primary care medical home,Veterans Health Administration[PowerPoint presentation on theInternet]. Presented at: PCPCC An-nual Summit. 2009 Oct 22; Wash-ington, DC. Available from: http://www.pcpcc.net/files/PCPCC-10-09-P1-Shear.ppt

40 Rittenhouse DR, Shortell S, Fisher E.Primary care and accountable care—two essential elements of delivery-system reform. N Engl J Med. 2009;361:2301–3.

41 Nutting PA, William L, Miller WL,Crabtree BF, Jaen CR, Stewart EE,et al. Initial lessons from the firstnational demonstration project onpractice transformation to a patient-centered medical home. Ann FamMed. 2009;7:254–60.

42 Grumbach K, Mold JW. A health carecooperative extension service:transforming primary care andcommunity health. JAMA. 2009;301(24):2589–91.

43 Meyers DS, Clancy CM. Primary care:too important to fail. Ann InternMed. 2009;150(4):272–3.

MAY 2010 29:5 HEALTH AFFAIRS 7

ABOUT THE AUTHOR: PAUL GRUNDY

Paul Grundy hashelped IBM lead theway in transformingthe health caresystem.

As global director of healthcaretransformation at IBM, Dr. Paul Grundyis trying to shift health care deliveryaround the world toward consumer-focused, primary care–based systems.Yet his father’s death last yearbrought home to him “why I fight sohard to change what we buy for ouremployees, our parents, our children. Isaw how my father’s primary carephysician—based on how she waspaid—lacked the incentive and theability to coordinate my father’s care.So much was done to him and not forhim. We can do better.”

IBM has led the way for othercorporations to transform the healthcare system, after concluding that “wethe buyers have been part of the

problem in not demanding systems ofpayment and practice organizationthat encourage and enable theaccessible and coordinated patient-focused primary care we desire,” hesays.“There is no money paid for the

necessary investments in teams andhealth information systems,” Grundycontinues. “Current payment methodsreward medical procedures anddiscourage spending time withpatients in such essential activities ashistory-taking, diagnosis, andprevention. This must change.”A social entrepreneur and speaker

on global health care transformation,Grundy, 58, is president of thePatient-Centered Primary CareCollaborative—a coalition he led IBMin creating in 2006, one dedicated toadvancing a new primary care modelcalled the patient-centered medicalhome. He is an adjunct professor atthe University of Utah’s Departmentof Family and Preventive Medicine.Before joining IBM in 2000, Grundy

was a senior diplomat in the StateDepartment and the medical director

for International SOS, the world’slargest medical assistance company,and for Adventist Health Systems, thesecond largest nonprofit medicalcenter in the world. He went tomedical school at the University ofCalifornia, San Francisco, and trainedat the Johns Hopkins University.The son of Quaker missionaries, he

grew up “in the poorest country in theworld—Sierra Leone,” he says. “Thisupbringing helped instill in me a needto stand up for transformation.”Individuals and small groups canchange history by practicing the lawsof social change—such as sharing acommon purpose or intent.”To Grundy’s way of thinking, in

health care “less is often more.” Atleast the uninsured, he says, areprotected from unnecessary surgery,or other forms of overtreatment andtoxic care that the current health caresystem encourages. “The terrible truthis that you can no longer count on theprofessionalism of the doctor to dothe right thing. If money can be madeoff your body, most likely it will be.”

Urgency Of Problem

8 HEALTH AFFAIRS MAY 2010 29:5