The Patient-Centered Primary Care Collaborative is a US not-for-profit organisation supporting and promoting innovation in medical homes. Our group attended their annual conference today, and not surprisingly, there was considerable discussion and concern about the potential impact of the Trump presidency on affordability in health care. As in Australia, changes in government inevitably lead to changes in rules and funding mechanisms for health services - not always in the best interest of patients.

Sustainable payment mechanisms for high performing primary care were on the agenda - much of it from the payer perspective, although the different perspectives and tension between affordability for payers and affordability for consumers was acknowledged. There was also discussion about how person-centred, team-based primary care could be scaled up to ensure appropriate care was available for all people.

We also learned some cultural lessons, particularly about queuing at the conference lunch buffet where military personnel were asked to take the lead; and had the opportunity to highlight how comparatively well Australia performs on health expenditure vis-a-vis the United States.

Some take-away messages from the day:

Access and affordability

Poor access to healthcare for some people in the US directly relates to poor health outcomes. Affordable healthcare is key to positive health outcomes, and we reflected on the value of Australia's approach to universal health. Hearing about healthcare being discussed through a market lens is not surprising, but nonetheless disconcerting.

Patient-centred medical home model

A whole of life approach to care, coordination, access, equity, patient support and engagement are central to the medical home model.

Role of primary care clinicians

Are clinicians a gateway to coordinated care, or gatekeepers to the health system?  Commentators noted that patients want the former.  There was a view amongst our group that seeing clinicians as a gateway to coordinated care was a positive vision for the primary care role in facilitating and delivering health care.

Team-based care

There's more to the team in the US model of a medical home than general practice. Nurses, social workers, community health workers, pharmacists, nurse practitioners, physician assistants, peer workers and others all play a role, and/or take the lead.

Change management and payment reform

Changes to payment models need to be associated with proactive change management in order to be positively adopted. The narrative needs to focus on health and what's important for consumers, not just about cost reduction.

Payments

Primary care providers are being asked to do more - and that's reasonable - but are we prepared to pay more, or are we asking providers to do more with less reward?

Accounting for every single transaction in primary care is unproductive and time-costly; a comprehensive payment with support for infrastructure may be an alternative. There are potential benefits in tailoring fee-for-service, working alongside payments for 'packages' of care.

Perverse incentives can be associated with medical homes including receiving payments for patients who are subsequently referred on to more costly specialist care.

Payments need to take account the true cost of care including time spent with patients. It may be cost-effective to consider applying funding to support social needs (eg housing, food).

There is a tension between introducing alternative care models, eg telehealth, and introducing new costs, even if the alternative models might ultimately lead to savings. Kaiser Permanente was cited as an example of the disruptive change which will drive payment reform - more than half of all physician visits at Kaiser Permanente are now via smartphone, videoconferencing and e-visits.

Consumers

Shared decision-making and quality care are fundamental rights for consumers: comprehensive payments need to account for this.

Like Australia, US organisations are also grappling with how consumers might be more meaningfully engaged in healthcare.  The US Center for Medicare and Medicaid Innovation acknowledged it faced difficulty communicating with consumers, including about costs, and in engaging with them in co-design.

Consumer engagement takes a lot of time and commitment, and needs to be a positive experience for both provider and consumer. Shifting power dynamics creates uncertainty, and requires building of relationships and trust, as well as training.