The article “A Proactive Approach to Controlled Substance Refills” [November/December 2010] left me speechless. I realize that the vast majority of practices are organized in the same way as the authors' and that many practices likely find their advice useful. However, as I read, I found myself wondering, how are processes like these sustainable, and how exactly do they further patient-centered care? Why spend hours of unpaid time organizing a process that generates more unpaid work? And why would I divorce medication prescribing from provider interaction?

Articles like this one abound. One month an article describes a great way to teach diabetes care, and the next month it's how to make sure all six year olds have completed a school asthma action plan. Disease-oriented programs are everywhere, forcing physicians to run faster and faster to check off boxes in a system so fragmented that there are specific programs for specific problems.

In lieu of disease-specific care, I suggest patient-centered care. Physicians should consider managing their panel sizes so that they can offer improved access. When the patient needs a medication refill, the patient calls the office to make an appointment. The patient is seen that day, and anything else the patient needs is taken care of then as well.

For me, efficiency means not wasting the patient's time. Patient-centered care puts the focus of “do today's work today” on the patient's needs, where they belong.

Authors' response:

Dr. Antonucci's comments aptly capture the frustration that many of us feel about the lack of system and financial recognition of population-based and patient-centered care. “Doing today's work today” is a fabulous model to strive for. Unfortunately, in many clinical settings, ours included, the demand of underserved patient populations greatly exceeds the provider and resource supply.

As stated in our article, “In clinics with high demand or many part-time providers, monthly visits are not always possible.” In such situations, managing panel size to offer open-access scheduling is not possible because patients cannot receive care elsewhere. As a result, innovative approaches to meet the patient's needs with high-quality, evidence-based medical care are needed. Group visits, nurse visits, ancillary visits and the use of trained lay educators are examples of such efforts we use to help meet the needs of our patients, despite the supply and demand mismatch. Our approach to controlled substance refills has been a successful model that allows unbiased, regular toxicology screening and provider oversight in the challenges of our environment.

We join Dr. Antonucci in looking forward to a health care system that provides access to everyone in a patient-centered, open-access model that makes our approach no longer needed.