Providing effective chronic care management for a panel of patients is a challenge that is often under valued intellectually and financially. As a result, large numbers of internists have left office-based practice for hospitalist medicine or other pursuits, and the nation faces a profound shortfall in primary care providers, especially with the passage of the Affordable Care Act. While the patient-centered medical home concept attempts to increase financial support for chronic care activities, the implementation and financial support for this framework remains problematic.
A recent article, “Defining Patient Complexity From the Primary Care Physician’s Perspective,” has become one of my favorite points of reference (Ann Intern Med. 2011;155:797-804). The cohort study, out of Boston, quantitatively proposes what any experienced internist knows by years of experience: that psychosocial issues are just as important – if not more so – as various combinations of comorbidities in the management of chronic disease. Office-based physicians identified different attributes of patient complexity than those elements routinely used by weighted formulas to assess administrative databases. From their experience, practicing physicians said that substance use, behavioral disorders, and economic challenges are the key factors that determine patient complexity and that ultimately affect their ability to manage their health.
This article is an important reference to provide to nonclinical policymakers who increasingly use administrative tools to assess the productivity and clinical impact of office-based professionals. Complexity is more than combinations of diabetes, cardiovascular disease, and pulmonary disorders. It is about managing people and their quirky personalities, beliefs, and lifestyles that play havoc with clinical guidance in a time-compressed office visit. Failure to capture these components of complexity in performance metrics could penalize those remaining effective practitioners who attempt to care for more difficult patients. Perhaps health homes with targeted case management will support primary care physicians and help achieve “accountable” benchmarks for care. Otherwise, truly complex patients as perceived by their physicians will find fewer offices willing to provide them an accommodating medical home.