Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care

Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed

Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care

Primary care is essential to the effective and efficient functioning of health care delivery systems, yet there is an impending crisis in the field due in part to a dysfunctional payment system. We present a fundamentally new model of payment for primary care, replacing encounter-based imbursement with comprehensive payment for comprehensive care. Unlike former iterations of primary care capitation (which simply bundled inadequate fee-for-service payments), our comprehensive payment model represents new investment in adult primary care, with substantial increases in payment over current levels. The comprehensive payment is directed to practices to include support for the modern systems and teams essential to the delivery of comprehensive, coordinated care. Income to primary physicians is increased commensurate with the high level of responsibility expected. To ensure optimal allocation of resources and the rewarding of desired outcomes, the comprehensive payment is needs/risk-adjusted and performance-based. Our model establishes a new social contract with the primary care community, substantially increasing payment in return for achieving important societal health system goals, including improved accessibility, quality, safety, and efficiency. Attainment of these goals should help offset and justify the costs of the investment. Field tests of this and other new models of payment for primary care are urgently needed

Evaluation of a National Curriculum Reform Effort for the Medicine Core Clerkship

BACKGROUND: In 1995, the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM) developed and disseminated a new model curriculum for the medicine core clerkship that was designed to enhance learning of generalist competencies and increase interest in general internal medicine. OBJECTIVE: To evaluate the dissemination and use of the resulting SGIM/CDIM Core Medicine Clerkship Curriculum Guide. DESIGN: Survey of internal medicine clerkship directors at the 125 medical schools in the United States. MEASUREMENTS AND MAIN RESULTS: The questionnaire elicited information about the use and usefulness of the Guide and each of its components, barriers to effective use of the Guide, and outcomes associated with use of the Guide. Responses were received from 95 clerkship directors, representing 88 (70%) of the 125 medical schools. Eighty-seven (92%) of the 95 respondents were familiar with the Guide, and 80 respondents had used it. The 4 components used most frequently were the basic generalist competencies (used by 83% of those familiar with the Guide), learning objectives for these competencies (used by 83%), learning objectives for training problems (used by 70%), and specific training problems (used by 67%); 74% to 85% of those using these components found them moderately or very useful. The most frequently identified barriers to use of the Guide were insufficient faculty time, insufficient number of ambulatory care preceptors and training sites, and need for more faculty development. About 30% or more of those familiar with the Guide reported that use of the Guide was associated with improved ability to meet clerkship accreditation criteria, improved performance of students on the clerkship exam, and increased clerkship time devoted to ambulatory care. CONCLUSION: This federally supported initiative that engaged the collaborative efforts of the SGIM and the CDIM was successful in facilitating significant changes in the medicine core clerkship across the United States