PROBLEM: FULL VALUE OF PRIMARY CARE HAS YET TO BE REALIZED REALIZED

The well-established value[29-31] of primary care involves better quality[32], better health, lower cost, as well as lower inequity[25, 26, 33-43]. There is, though, a misalignment between these benefits and the cost of improving primary care. The benefits “accrue [to society] at the level of the patient’s lived experience outside of health care, and at the levels of the

healthcare system, community, workforce and population” (p.604); thus, the value of primary care can be found largely by looking outside the health care system[28]. However, in the US, the cost of investing in improvements to primary care, like PCMH, is primarily borne by independent primary care clinics as well as by integrated HSDOs[28].

Along with the misalignment of benefits and costs, there is also a paucity of experience with

“the process and intended and unintended consequences of transforming current practices into [PCMHs]”[28] (p. 601). This situation places primary care HSDOs and clinics in a difficult position, where they must choose between undertaking a major transformation, at their own expense, with a limited understanding of how to succeed, and maintaining the status quo (with its own problems, discussed later).

36 In order to learn how the hundreds of pilots and demonstrations across the US worked to overcome these challenges, the US Agency for Healthcare Research and Quality commissioned research (in 2010) “to better understand challenges faced by primary care practices as they transform into PCMHs”[3] (p. 1). In so doing, the hope was to narrow the gap between theory and practice. Each site selected has contextual as well as implementation differences[8, 44-57].

The effort at the University of Utah Community Clinics occurred semi-autonomously from the parent organization, University of Utah Health (herein the HSDO). It began in 2003, following a business turnaround, with innovation allowed and encouraged[58].

University of Utah Health, the Mountain West’s only academic health care system, is one of the health systems providing care for Utahans and residents of five of the surrounding states.

Its three-part mission involves excellence in: patient care, education and research. University of Utah Health is an integrated HSDO, including four hospitals, which provides primary care in 12 community clinics. It also has its own health insurance plan: University Health Plan[59].

At the time data were collected (2011), there were 10 community clinics, with 70 clinicians, which served 100,000 active patients (more than 200,000 primary care visits) per year. Clinics ranged in size, with the smallest clinic having four clinicians and approximately 9,000 visits and the largest clinic having 14 clinicians and approximately 17,500 visits[56].

The HSDO’s community clinics employ management staff consisting of healthcare

administrators, medical directors, and nurse managers. Among other duties, mangers are tasked with staying profitable, with any profits being absorbed by the HSDO.

Figure 1.1 displays the 10 community clinics (red points) along with similar clinics (blue points).

There is no internal competition for 4 of the 10 clinics (as shown by the red two-mile, yellow five-mile and blue ten-mile radius circles around those clinics). They are all located in the Greater Salt Lake City metropolitan region[60].

37 Figure 1.1 Map of the 10 University of Utah Community Clinics, Greater Salt Lake City Metropolitan Region, Utah, US

NOTE: This Figure displays the Greater Salt Lake City metropolitan region. The 10 community clinics (red points) and similar clinics (blue points) are shown. No internal competition exists for 4 of the 10 clinics (as shown by the red two-mile, yellow five-mile and blue ten-mile radius circles).

38 Now, in 2017, it has been almost 10 years since the earliest PCMH pilots were launched. While no meta-analysis or systematic literature review exists that would point to the ability of PCMH to deliver the promised value, peer-reviewed publications do provide some insights: (1) transforming primary care is challenging[61-63], (2) clinics vary in how they put the concepts of PCMH into practice[16, 54, 63, 64] and (3) clinics vary in the extent to which they improve outcomes (e.g., cost, quality, patient satisfaction)[15, 65-70].

Despite this variation, the consensus on the merits of primary care (and thus of PCMH implementation as the current blueprint for PCT) is strong enough to ensure that PCMH adoption is likely to continue growing – whether through public policy or organically. This means clinics adopting PCMH will not be able to begin their transformation with certainty of succeeding. Improvements to theory, such as a better understanding of the complex interactions between the primary care tenets in transformation, have the potential both to improve clinics’ chances of success and to refine researchers’ questions.

The US Institute of Medicine reaffirms the importance of primary care as the “logical

foundation of an effective health care system” (p. v) and as being “essential to achieving the objectives that together constitute value in health care” (p. 2)[71]. The past decades have seen a growing recognition of the value of primary care and a growing sense of urgency to narrow the gap between theory and the reality of primary care in practice.

The transformation of primary care sought by PCMH matters because it is designed to address important problems arising in health systems where the primary care tenets are deficient, including:

There is a need for more comprehensive care: Half of the US population suffers from chronic conditions[72]; these conditions are uncontrolled for: half of those with hypertension[73], more than 80% of those with hyperlipidemia[74] and 43% of those with diabetes[75]. McGlynn et al. report that clinicians are only able to provide 55% of chronic and preventive services[76]. Estimates indicate that it would take 21.7 hours per day for a clinician to deliver comprehensive services to a panel of 2,500

patients[77-79].

There is a need for greater access: At times, the US population also uses hospitals for conditions that are considered primary care treatable and/or primary care

preventable, whether entering the Emergency Department, hospital admissions or readmissions[80]. Research has shown that greater access to clinicians addresses primary care treatable concerns and reduces preventable hospital visits[81-83].

39 There is a need for more coordination among providers: The US population also experiences care fragmentation, which is when there is insufficient infrastructure to have specialty providers coordinate patient care with the clinician. This can result in adverse consequences, in particular for patients with chronic and mental health conditions[15-18, 84, 85].

There is a need for an added measure of continuity between provider and patient:

Patients’ longitudinal continuity with a provider is reinforced by the interpersonal relationship that forms between them, and vice versa[86-88]. This relationship enhances the provider’s ability to be person-focused and to be aware of the person’s context such that “care [is] integrated and prioritized across acute and chronic illness, preventive, psychosocial, and family care”[89] (p. 294). Low continuity exacerbates the deficiencies in the other three tenets described above[90].

These societal problems are felt deeply in the US as its citizens recognize that the US has high health care spending and only moderate outcomes[76, 91, 92]. These trends persist when the US is compared to other countries[25, 26, 33-36, 93, 94].

The US is not unlike other World Health Organization Member States in this respect. In the 2008 World Health Organization report Primary Health Care - Now More Than Ever[95], Director General Margaret Chan laments: “despite enormous progress in health globally, our collective failures to deliver in line with [Alma Ata] values are painfully obvious and deserve our greatest attention” (p. viii). As part of “a shift towards… more comprehensive thinking about the performance of the health system as a whole” (ibid.), Member States have demanded knowledge regarding how they can achieve more “equitable, inclusive and fair”

health systems and meet the growing demand for primary care (ibid.). The World Health Organization calls for “re-organiz[ing] health services around people’s needs and expectations, so as to make them more socially relevant and more responsive to the changing world”, as a crucial step toward resolving the “intolerable gaps between aspiration and implementation”

(p. ix)[95].

40 1.2.3 THEORETICAL AIM & OBJECTIVE #1

The dissertation relies on the following problem statement for this research:

Primary care transformation has been and continues to be an elusive target. In the short term, implementation is hard and failure abounds. In the long term, some practices reach successful implementation. We lack sufficient understanding of the structure of primary care, and of the policies that can impact this structure.

This problem statement is the cumulative result of all phases of this dissertation. As presented in Appendix C, the Scoping Study, tensions were found to exist within the structure of primary care such that the four tenets of primary care and the context of transformation at the HSDO influenced each other, where the hoped-for levels of implementation could not be reached in all tenets at the same time. These tensions involve complex interactions within the underlying causal structure of primary care which contribute to the observed failure and success modes.

While the value of the primary care tenets is well understood, current theory lacks an understanding of the complex interactions between them as well as their interaction within the system of care already in place. This understanding is necessary in order to realize the aspirations of health care systems worldwide.

My theoretical aim is to develop a better theory of primary care transformation. This aim has one theoretical objective (Objective #1): to develop a grounded, dynamic theory of PCT in order to build understanding of the key structures generating the primary care health service delivery system behaviors of difficulty, failure and success that HSDOs experience when implementing system improvements such as PCMH. In meeting this aim, this research will develop useful theory for anyone engaged in PCT (including clinicians, managers and other influential policy-makers in health service delivery systems), facilitating improved

transformation.

41