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November 29, 2022
View from Here
Primary Care Transformation Primary Care Investment
Christopher F. Koller
Nov 15, 2023
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A friend of mine was working her way through social work school by tending bar. She wanted to know if her time at the pub could qualify for her practicum – the internship experience required by her school. “After all, I spend a lot of time listening to people tell me their problems,” she reasoned to me.
The school was not persuaded, but I follow her logic. Like the theme song from the 1980s sitcom “Cheers” about the denizens of a Boston bar (made popular way before Applebee’s repurposed it), there’s great comfort in being with people who know you, accept you, and will listen to you.
Making your way in the world todayTakes everything you’ve gotTaking a break from all your worriesSure would help a lotWouldn’t you like to get away?….. Where everybody knows your nameAnd they’re always glad you cameYou want to be where you can seeOur troubles are all the sameYou want to be where everybody knows your name. 1
Making your way in the world todayTakes everything you’ve gotTaking a break from all your worriesSure would help a lotWouldn’t you like to get away?…..
Where everybody knows your nameAnd they’re always glad you cameYou want to be where you can seeOur troubles are all the sameYou want to be where everybody knows your name. 1
A sense of connection matters — when choosing a spot to relax in the evening or when seeking health care. And unlike a bar, having a familiar place for care is always associated with positive health outcomes. Acres of research have demonstrated the beneficial effects for people who report a usual source of care compared with those who don’t, including:
These results are documented by outcome measures and patients’ own responses. The specific characteristics of that source of care affect its quality. Barbara Starfield documented the particular importance of the “4Cs” of first contact, continuity, comprehensiveness, and coordination. But what matters first and foremost is that people have someplace — any place — they feel connected to for medical care.
None of this should come as a surprise. It is why parents often prioritize finding a regular clinician for their children’s health care and pregnant women desire a regular setting for obstetric care. It is why the dreaded health maintenance organizations of the past wanted their enrollees to declare their primary care provider and built sometimes-oppressive benefit designs to encourage their use and consultation. A usual source of care matters because prevention makes a difference, but diseases still happen and are scary. Medical science knows stuff, but care is about relationships, too.
So public policy should make it as easy as possible for all people to establish and maintain that relationship. A recent report from the Primary Care Collaborative (PCC) documenting the steady decline in people in the United States reporting a usual source of care is a real cause for concern.
The steady 20-year decline appears unaffected by the expanded rates of insurance coverage with the passage of the Affordable Care Act over 10 years ago (Figure 1). Although the drop has been particularly steep for the dwindling number of uninsured, it has also occurred among those with Medicare and Medicaid, as well as private insurance (Figure 2). This cross-payer finding indicates that the problem is not merely one of increased cost sharing in commercial insurance benefit designs in which beneficiaries pay more in premiums, deductible, or out-of-pocket costs like copays.
The report also shows a whopping 50% variation between states in the portion of the population reporting a usual source of care, although the report did not examine changes over time by state (Figure 3). Some of this appears — logically enough — to be driven by provider supply. States with few primary care providers per capita like Nevada and Mississippi score most poorly in usual source of care, and primary provider-rich Massachusetts does pretty well. But physician supply does not explain all the state variation. The District of Columbia fares poorly in the measure despite having more primary care physicians per capita than any state. Not surprisingly, the report finds that women, children, and the elderly population are more likely to report a usual source of care since those populations seek more routine care.
The decline in the usual source of care measure presents grave challenges to anybody concerned with population health and health equity. Access to strong primary care is the only health care service associated with better population health. Yet Black and Latino nonelderly adults (under age 65), are significantly less likely to have a usual source of care compared with Whites — a trend that has persisted over time (Figure 4).
Having one’s care preferences taken into account — receiving truly patient centered care — is both a fiscal and moral imperative for health care, and part and parcel of having a usual source of care. Research from the University of Massachusetts Boston and Community Catalyst shows that person-centered care is better, less expensive and — for people of color and low-income households — more elusive. The same research also shows that having a usual source of care can decrease the likelihood of never having care preferences considered among older people of color and people in low-income households.
But if having a usual source of care is good for individuals and the population, why is it withering? One analysis would peg this as an indictment of our health care system – a disorganized mass of hard-working but poorly coordinated clinicians, dominated by cults of specialization and profit, which treats patients as a collection of conditions navigating a supposed health care services “market.” The PCC study, drawing on the 2021 National Academy of Science Engineering and Medicine report on implementing high-quality primary care, cites four approaches to improving access to a usual source of care in such a world:
These initiatives are all necessary, but I wonder if they are sufficient. If the declines in usual source of care are consistent across all regions of the country, as well as all payer types and all populations, then the measure may be measuring the prevalence of social isolation. Are there connections between the decline in people reporting a usual source care and the increased social fragmentation observed in Robert Putnam’s Bowling Alone or with increasing mid-life mortality rates documented by Anne Case and Angus Deaton’s Deaths of Despair and the Future of Capitalism and in the research of Steven Woolf and Heidi Schoomaker?
If so, helping establish a usual source of care for all is not just wise health care policy but important social policy for the health of the country, like universal education, public safety, and public health. As with these other governmental priorities, establishing the societal importance of a usual source of care brings accompanying individual rights — to have regular access to an adequate supply of competent clinicians without fear of financial ruin — but also responsibilities, such as committing to open and regular communications with that team, as in any other healthy relationship.
Health care is fundamentally a healing relationship, not a transaction. The data are clear that fewer people are reporting that kind of connection with their clinicians in the US. And that is a real problem. The folks in “Cheers” repeatedly went to the bar not just for the spirits but for the spirit — a place where people felt connected and participated in healing relationships of a sort. Should we expect anything less of our health care system and how we engage it — not just clinical competency but a place where we know one another’s names?
1 Gary Portnoy & Judy Hart Angelo
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