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October 30, 2023
Primary Care Transformation
Mary Louise Gilburg
Aug 15, 2023
Apr 3, 2023
Feb 22, 2023
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Medical research and the US health system and are largely designed to prevent and treat disease but not to keep a whole person healthy, say many primary care proponents. In this Q&A, Kurt C. Stange, MD, of the Center for Community Health Integration at Case Western Reserve University, William L. Miller, MD, of Lehigh Valley Health System and University of South Florida Morsani College of Medicine, and Rebecca S. Etz, PhD, of Virginia Commonwealth University, explain the craft of generalism and why it’s important to have primary care teams that respond to the needs of the whole person in a discussion of their Milbank Quarterly centennial issue Perspective. In the interview below, the authors explore how primary care works to advance the health of people and populations, and offer policy solutions to increase research and investment in primary care.
This piece is the eighth and final Q&A in a series with authors from The Milbank Quarterly’s special issue, The Future of Population Health: Challenges and Opportunities.
Stange: We have good evidence that if you base a system on primary care, you get better health for the population at less health care expenditure and with greater equity and quality of care. Yet, most research from a reductionist disease-specific paradigm shows primary care providing less evidence-based care of specific diseases. The health care system optimizes the parts while the whole is getting worse and costs are skyrocketing. The paradox is that despite apparently offering less quality on the parts (disease) care, primary care produces better quality on the whole (people and populations).
Stange: Primary health care is made up of four components: (1) primary medical care (the focus of our paper), (2) public health and community organizations related to health, (3) the social drivers and influencers of health, and (4) the people who help in the care of somebody who is experiencing sickness, which is almost always kith and kin or your social media or an internet search. In the United States we collapse these four components under primary care. Policymakers need to differentiate between those four components and think about how their policy addresses all four and helps them work better together.
Stange: Since we have so many measures for prevention and chronic disease management, we’ve forgotten that primary care is also in large part about identifying and helping with what the person needs in the moment. Primary care is about being accessible for acute care as well as chronic care, as well as mental health, prevention and all the things that fall between the cracks.
Etz: The chronic care model was a wonderful agent for change, but it also caused us to overly focus on chronic disease management and prevention. Our failure to understand that primary care handles about 80% of acute care in the country means that we failed to provide it with the necessary resources. During COVID, there were tremendous amounts of unnecessary death among not only the population but also our clinician workforces. Primary care doctors died from COVID five times more than any other profession, in part, because we failed to recognize at a policy level that they were the frontline for acute care.
Miller: A generalist follows three simple rules all at the same time all the time. They’re continually recognizing who the patient is and what information they are sharing, immediately prioritizing what information matters, and personalizing care so that patients take the appropriate action to help themselves when they leave.
Stange: Primary care clinicians often do things that fly in the face of narrow, evidence-based guidelines to personalize care for what a person needs right now. Investing in patient relationships over time creates an ongoing conversation with real added value. When you come in with a complaint, it’s not an urgent care center where you’re starting from scratch.
In fact, discussion of family comes up during half of new patient visits and during a quarter of visits by established patients. It’s part of the context for caring for the individual and for caring for the family. During 18% of visits to a family physician, care is provided to another person besides the identified patient. It’s a hidden value because there is not a way of measuring that.
Miller: If all primary care becomes urgent care or algorithm- or protocol-driven, all that gets lost and there is then no added value and population health won’t get better.
Stange: One top-down approach is physician-led accountable care organizations (ACOs). Physician-led ACOs tend to focus on primary care as the first contact and then selectively use specialized in-hospital services, which is how they control costs and improve the integration and personalization of care, which improves equity by tailoring to their community needs.
Another bottom-up approach is direct primary care in which people pay a monthly or annual subscription fee that pays for all their primary care. The care tends to be delivered by primary medical practices with a small panel size of around 500 patients. In this model, clinicians can take time with people because they’re paid by subscription, so they’re not incentivized to bring people in all the time like in a fee-for-service model.
Miller: In a healthy primary medical care system, there will always be a lot of variation in how the practices look and how they organize because they are responsive to the needs of the place where they are situated, the people who live there, the resources that are available, and the contextual issues that are in play, which increasingly will be environmental issues. Policy should allow for that organizational variability. Most policies now look to standardize, reduce, and look at individual measures, and pay no heed to relationships and how to preserve them over time.
Etz: In the immediate future, there needs to be a primary care emergency fund. Primary care handled 99.8% of all respiratory illness before the pandemic and yet when we were hit by a respiratory novel disease, it received less than 3% of any emergency federal funds.
Miller: Every primary care practice in the health system is understaffed right now. Staffing is turning over all the time because they’re just treated as cogs, not as part of an actual team. In a family medicine practice, for example, relationships with the person on the phone, the person who first greets you, the person who puts you in the room are as important as the relationship with the clinician. Human resource policy should allow for primary care support staff to be paid differently to build the necessary team-based or jazz ensemble-based workforce that can be tracked.
Stange: As was recommended in a recent report by the National Academies, we need to increase the percent of health care spending on primary care from 6% to 12%. Also, looking at loan repayment and other state-level things that can be done to support people going into primary care is important. We need the nurse practitioners and physician assistants working in primary care, but our professional organizations are fighting with each other for turf rather than trying to work together. Policies that develop the workforce and support interprofessional work at the state level are helpful.
Etz: Evaluation and management (E&M) codes used for billing could be changed to allow for better rates for primary care or other disciplines that use a lot of cognitive work in their delivery of care. During the pandemic, we established payment parity for video and phone-based care, so there is a precedent of adjusting reimbursement rates.
Many policies aim to increase payment to primary care, but the increased payments actually go to health systems and never trickle down. Policies should require health systems to demonstrate that added resources are received by primary care practices or clinicians through investments in infrastructure or the workforce.
We need to tell stories about primary care that the public and policymakers can more easily embrace. We need to provide them with the research base that helps generate a good story, or they’re not going to tell our story. Primary care receives 0.2% of National Institutes of Health funding. We have the National Center for Excellence in Primary Care Research, but we choose not to fund it.
Even if all the best policies are employed, it will take time and resources to be actualized in primary care setting. There was a primary care extension program created as part of the Affordable Care Act to facilitate practice redesign, but like many legislative changes in primary care, it effectively wasn’t implemented because it came with no funding. If policymakers wanted to have an immediate impact, they could fund existing policies.
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