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November 15, 2023
View from Here
Primary Care Transformation Population Health Primary Care Investment
Christopher F. Koller
Oct 3, 2023
May 9, 2023
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Primary care in the United States is in deep trouble. Facing increasing workloads as they backstop dysfunctional systems of care, more primary care clinicians are leaving the workforce, and they are not being replaced fast enough. As a result, more and more patients are complaining about a lack of appointment availability and fewer report a usual source of care. Since primary care is the only health service where an increased supply is associated with improved population health and health equity, a shortage of primary care clinicians is, to put it mildly, a problem — one that will only worsen as our population ages.
In this context, a new U.S. Department of Human Services (HHS) issue brief on primary care is a helpful step towards a comprehensive commitment to addressing these problems. While the brief leaves some important questions unanswered about where the Biden Administration’s relationship with primary care is going and at what speed, advocates should see it as an opportunity to deepen the Administration’s commitment to primary care, in part, by organizing themselves.
Anticipating the weakening of primary care, “Implementing High Quality Primary Care,” the 2021 National Academy of Science Engineering and Medicine’s (NASEM) report labeled high-quality primary care as a common good, identified five broad areas of work (payment, access, workforce, information technology, and accountability) to strengthen it, and called on the federal government to lead the effort. The authors’ reasoning was simple. Public institutions steward common goods, and since public policy had created the environment hostile to primary care, those policies had to be amended, with both legislation and improved use and coordination of the many levers at the disposal of federal and state governments.
Two years later, the Biden Administration has responded, with HHS releasing their issue brief on November 7. The brief comes as the result of the HHS Initiative to Strengthen Primary Health Care launched in 2021. A veritable “kiss through a screen” — in which virtual signs of affection substitute for the real deal — the brief falls short of the anticipated HHS-wide plan for primary care that was to result from the initiative.
The brief states the value of primary care and describes its perilous state. It compiles an impressive and comprehensive list of current HHS efforts, organized into the NASEM report’s five areas of work. In addition, it lists many future commitments — such as strengthening the primary care teams and improving access to primary care relationships for Medicaid and Medicaid beneficiaries — in each of these areas, with the notable exception of payment reform.
That said, the brief leaves several questions unanswered. According to the brief, “HHS is committed to continuing an HHS-wide approach to advance actions to strengthen primary care.” What is the plan and accountability for carrying out these commitments? The brief is silent on the structure and process for doing so. Who is responsible for this effort and what authority and funds will they have? How can this work continue under new administrations?
Public accountability will be important as the steps identified in the report are implemented, progress is assessed, and the future agenda is set. A newly established standing committee on primary care at NASEM could be a valuable partner in this process.
Similarly, while it is encouraging that an accompanying National Academy of Medicine commentary is signed by agency leadership across HHS, to succeed, this work must be supported by the White House and the HHS Secretary’s office itself. Priorities start at the top. Moreover, progress on the administration’s population health priorities of health equity, pandemic resilience, addressing opioid misuse, and improving behavioral health, especially among children, will not be met without a strong and sustainable primary care delivery system.
The brief ends with a call for private sector partners in this work. “Strengthening primary care requires a whole-of-society effort,” it states. “HHS calls on other actors, such as payers, providers, communities, academia, and state, local, territorial, and tribal governments, to take action with us.”
This is an important admonition. Primary care may be in crisis but is not a passive patient receiving emergency care. Good primary care is based in part on productive partnerships. Primary care advocates and state and federal officials must adopt a similar stance on potential solutions. This starts with organizing and maintaining broad coalitions of consumers, provider groups, community health centers, payers, and employers around their priorities, then building constructive, mutually accountable relationships with policymakers and regulators.
A kiss through a screen is not enough. Organizing coalitions, building relationships, and developing and implementing the needed policy changes in both legislation and regulation will take persistence and strategy. The HHS brief is an important next step in what promises to be a long journey towards a primary care delivery system strong enough to meet the country’s pressing health needs — one that demands a faster pace from all involved.
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