September 24, 2021
Dear Interested Readers,
Thinking About the (Compromised) Future of Primary Care
I have always thought of myself as a primary care physician. When I joined the practice at Harvard Community Health Plan as their only cardiologist in 1975 all of the medical specialists also had primary care practices. It was a good fit for me because I had become a cardiologist with the hope that specialty training in cardiology would help me be a more effective PCP given the fact that cardiovascular problems occur so frequently in the management of adult patients. My medical role model when I was in high school was an internist who also practiced cardiology. He did not realize in the fifties or sixties that his practice was a “cardiology medical home,” nor did I have the language in the seventies to know that my practice was a “cardiology medical home.” I was doing in 1975 at HCHP what the American College of Cardiology suggested was an innovation in 2015.
HCHP was founded with the concept of its medical specialists also being PCPs. Our oncologist, hematologist, infectious disease specialist, endocrinologist, nephrologist, and gastroenterologist all had primary care responsibilities as well as their specialty practices. It was an efficient way to practice. When a patient in the primary care practice of the gastroenterologist developed a cardiac concern I would see the patient. Sometimes the patients would “switch” to my practice if the cardiac issue was going to be a chronic problem. If a patient in my practice developed an inflammatory bowel problem they would be seen by our gastroenterologist and remain in that practice, and so it was with all of our medical specialists.
Without knowing what we were doing we were following a “medical home” model because we were coupled with nurse practitioners who would become adept at co-managing the specialty-related patients in their practice partner’s panel of patients. As much as I enjoyed seeing cardiology I also enjoyed the preventative care of patients. Sometimes I would ask a new patient why they had chosen to join my practice. It was common to hear that the patient had picked me because they had a family history of cardiac issues and deaths and hoped that by being in my practice they might avoid the issues of their parents or grandparents. As we moved into the eighties and were growing from the approximately 30,000 patients that we had in 1975 with one cardiologist at one site to over 300,000 patients in more than a dozen sites we changed the model and centralized much of our specialty care. Growth made relationships in the organization less intimate and all of our specialists except me gave up primary care. My accommodation to change was that technically, for purposes of billing and administration, when I worked in the specialty office I was a cardiologist, when I worked in internal medicine I was a PCP. My primary care/cardiology patients could see me in either office.
I really like the description of the innovation the ACC article talked about in 2015 that I experienced as reality forty years earlier. They write:
Even when a PCMH (Patient-Centered Medical Home) is able to reduce unnecessary specialty visits by better managing the health of a population, some patients will still require more costly specialty care, such as cardiovascular services. The management of cardiovascular conditions frequently involves complex care protocols and extensive multidisciplinary input. As a result, cardiologists often find themselves serving in a dual primary care/cardiology role. This places more responsibility on the cardiologist to find effective ways to ensure care coordination among all of the patient’s core providers and to balance the level of medical management and procedural care needed for each cardiology patient’s particular condition.
One approach gaining traction in the cardiology care arena is the specialist medical home model. In 2013, the National Committee for Quality Assurance (NCQA) launched the Patient-Centered Specialty Practice (PCSP) Recognition program, which is aimed at aligning specialty care models, including cardiology, with those of their primary care counterparts. The requirements of the PCSP program closely mirror those of the PCMH model and align with other measures and initiatives… such as CMS’ EHR Incentive Programs with regard to meaningful use and the Agency for Healthcare Research and Quality’s Consumer Assessment of Health Providers and Systems (CAHPS) patient experience tool.
Harvard Community Health Plan’s experience with the demise of an excellent clinical practice is a good example of how finance drives the delivery of care. I am not cynical but realistically I know that at the board meetings of the two systems where I am still a board member, we give much more attention to our balance sheet than to measurements of patient satisfaction or quality. We always know whether we are profitable, but we have little understanding of whether we have really done anything to improve the long-term outcomes of our patients. We focus on the volume of our visits and the procedures that we do that increase revenue, not health. There is much more emphasis on the number of “hearts, hips, and knees” done by the system than on whether or not our efforts add up to any progress toward a goal like the Triple Aim. I sometimes feel that if quality scores did not function as a boost to the revenue they would never be discussed or any effort applied to their improvement. I know that I may sound like a biased and crabby old dinosaur, but as I make my case for the hypothesis that we have lost our way I point to the declining longevity of Americans against a background of soaring costs, and our inept management of the challenges of COVID-19.
My biases and crabbiness were exacerbated and somewhat exonerated this week when I received my copy of the New England Journal of Medicine. One of the articles in the Perspectives section was entitled Revitalizing the U.S. Primary Care Infrastructure. It was written by an all-star cast of academic thinkers in primary care: Kevin Grumbach, M.D., Thomas Bodenheimer, M.D., M.P.H., Deborah Cohen, Ph.D., Robert L. Phillips, M.D., M.S.P.H., Kurt C. Stange, M.D., Ph.D., and John M. Westfall, M.D., M.P.H. The note at the end of the article points out that they are all members of the Primary Care Center’s Roundtable, a forum where the directors of primary care research and policy centers at America’s academic health centers and national family practice medicine organizations meet to exchange ideas and promote primary care.
In an article from the American Board of Family Medicine about the NEJM article which appeared first online before it was included in this week’s Journal we can read more about the expertise of the authors and the “Roundtable.” They write:
The 6 authors of the report (Drs. Kevin Grumbach, Thomas Bodenheimer, Deborah Cohen, Robert Phillips, Kurt Stange, and Jack Westfall) are members of the Primary Care Centers Roundtable, comprised of directors of many of the nation’s most prominent primary care research and policy “think tanks” based at universities and family medicine professional societies. Twelve additional members of the Roundtable endorsed the article. Three Roundtable members served on the NASEM Committee on Implementing High-Quality Primary Care. The Primary Care Centers Roundtable includes the following centers:
- Center for Excellence in Primary Care, Department of Family and Community Medicine, University of California, San Francisco
- Center for Primary Care Research and Innovation, Department of Family Medicine, Oregon Health and Science University
- The Center for Professionalism & Value in Health Care, American Board of Family Medicine Foundation
- Robert Graham Center, Washington, DC
- Center for Community Health Integration, Case Western Reserve University
- Larry A. Green Center, Virginia Commonwealth University
- Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine
- National Center for Family Medicine, Morehouse School of Medicine
- Department of Family and Community Medicine, University of Texas, San Antonio
I point out these affiliations in an attempt to underscore the fact that the NEJM article represents a consensus opinion from the organization that is the primary professional organization of family practice, The American Board of Family Practice (ABFM), and that the ABFM has close ties with the American Board of Internal Medicine and the American Board of Pediatrics, These three boards relate closely to most primary care practices across the country. The suggestions in the NEJM article are addressed not only to healthcare as a whole but specifically to the Secretary of Health and Human Services, The Honorable Xavier Becerra. In a way, I hope that we are reading Secretary Bacera’s mail. The authors begin with a statement that I doubt would create an argument with Secretary Becerra.
The United States has learned from the Covid-19 pandemic what is required of the federal government’s executive branch to tackle a national health crisis. In addition to presidential leadership, there must be a team with a single purpose that reports directly to senior leaders and that coordinates federal and state activities, uses a parsimonious set of measures to assess progress toward goals, and is accountable for results…These lessons can be applied to other critical health problems, including to the deficiencies contributing to decreasing life expectancy in the United States. Before the pandemic, the average life expectancy was already 3.4 years shorter in the United States than in other wealthy countries. One especially glaring problem is the country’s long-standing neglect of primary care.
The authors then point out that there has been an effort to suggest ways to address the huge problems that face primary care and the damage that deficient primary care does to the health of the nation now and that will worsen if steps are not taken to revitalize primary care.
A recent report from the National Academies of Sciences, Engineering, and Medicine (NASEM), Implementing High-Quality Primary Care, recognized a well-functioning primary care system as a common good and outlined an implementation plan for supporting U.S. primary care… [You can download the plan/book for free]…Two important elements of the proposed plan involve establishing a Department of Health and Human Services (HHS) Secretary’s Council on Primary Care and creating a scorecard to track progress in boosting state and national primary care infrastructure. These recommendations mirror essential components of the federal government’s vaccination implementation strategy.
After stating the obvious, that primary care is vital to the health of the nation, the authors give us some statistics to emphasize how vulnerable our primary care resources are. These numbers suggest that we are already experiencing a creep of increasing danger. In my mind, one of our greatest national tendencies is to disregard developing problems until they are disasters. I would point to climate change as one of the best current examples of that bad habit. Concerning our neglect of the deterioration of our primary care capabilities, the authors write:
High-quality primary care is vital but undersupported in the United States. In communities with more primary care resources, people live longer, health care costs are lower, and there is greater health equity than in areas with less primary care infrastructure. More than half of office visits in the United States are to primary care clinicians, yet primary care physicians make up only 30% of the physician workforce and are supported by only 5.4% of national health expenditures, and research on primary care garners just 1% of federal agency research awards. One in five Americans live in a federally designated primary care Health Professional Shortage Area. Primary care physicians earn 30% less than other physicians, on average, and they have among the highest rates of physician burnout.
What makes me upset is that even though we have known for more than a quarter-century that we have a problem, we are letting it get worse. Again, global warming is a good reference to point out that we have a habit of deflecting potentially deadly problems while focusing on less important concerns like avoiding taxes, reducing money spent on social services, and making abortions much harder to get. The assessment from the authors is:
…the situation is worsening. The first major report on primary care published by the Institute of Medicine (now the National Academy of Medicine) 25 years ago called for rebuilding this sector. Most of the report’s recommendations weren’t implemented, however, in part because no government agency or private entity had the authority to bring them to life. More recently, primary care professional societies issued the Joint Principles of the Patient-Centered Medical Home, which advocated for practice transformation and payment reform. The Center for Medicare and Medicaid Innovation (CMMI) has since conducted demonstrations of alternative primary care payment models, but none of these models has been widely implemented.
This last paragraph is a subtle accusation that fee-for-service funding is a disaster for primary care. Getting paid piecemeal for professional activities that you might do to support your healthcare factory that does “hearts, hips, and knees” may fund the construction of more operating rooms and bed towers to support more work on hearts, hips, and knees, but it does not support improving the health of the nation. Despite the fact that I know it is a minority opinion, I would go so far as to say that continuing FFS finance of healthcare is killing primary care and will kill many Americans who are delighted with their new hip. The authors are less blunt.
The realities of daily practice haven’t improved for most primary care teams. The share of the country’s health care resources that is invested in primary care is meager and declining. Between 2005 and 2015, the number of primary care physicians in the United States decreased from 46.6 to 41.4 per 100,000 people, and the proportion of nurse practitioners and physician assistants who work in primary care is dropping. Despite efforts to promote interest in primary care among medical students and residents, the proportion of graduates of M.D.-granting schools who match with family medicine residencies has remained at about 9% for the past decade — well below the level needed to replace retiring family physicians. Less than one in five internal medicine residency graduates pursue careers in primary care, down from half of such graduates 25 years ago. The growing mismatch between demand and supply reduces access to care for patients and intensifies burnout in the primary care workforce. Reflecting this imbalance, the number of per capita primary care visits decreased by up to 25% between 2008 and 2016, with the largest drops occurring in low-income communities, and average wait times for new appointments have increased.
Those numbers hide a situation that is even worse. Our primary care resources are much thinner in rural and inner-city America where our most vulnerable citizens live with a system of primary care that doesn’t measure up to what is available in many third-world countries. President Trump was famous for deriding “sh– hole countries.” Ironically, many of his most vociferous supporters would get better primary care if they lived in one of those “sh– hole countries.”
If you take the numbers as they are now, 41.4 PCPs per 100,000 people, and forget that many of those PCPs are near retirement or are emotionally “burned out,” and then imagine what is not true, that every American had equal access to primary care, you would calculate that we have one PCP for every 2,415 people. Optimal panel sizes for the way most doctors work in well supported pediatric practices are usually less than 1500, and I always found that even with very generous practice supports in adult primary care, panel sizes over 2000 created patient dissatisfaction with access and physicians and midlevel practitioners who were frequently burned out. When social issues and language barriers exist the number of patients that any single clinician can safely manage goes down rapidly. Add to all these concerns the fact that many of our PCPs are aging out of practice, and you understand why I have said for over twenty years that ultimately our workforce problems will be greater than our financial problems. The ready solution that many offer is to hire more “mid-level” practitioners: NPs and PAs. Well, that does not work because we are not producing them fast enough to fill the gap and many say “No thank you!” to primary care as they find their place in specialty practices.
It’s not a criticism, and I am sure the move is the product of years of study and thought, but the authors seem to “jump to a solution” after describing the dire state of primary care and the dangers that are growing for Americans as their access to care declines.
Among the many factors contributing to the neglect of primary care, including current payment systems, one critical deficit could be readily addressed: the absence of a government entity that is responsible for defining and overseeing implementation of a coordinated national primary care strategy. Primary care is a force for care integration, but the federal government’s approach to primary care is fragmented… Many…agencies have a hand in primary care, but their efforts aren’t well coordinated, and there is no central HHS team that has the express goal of revitalizing primary care and ensuring that all the pieces of a well-functioning primary care system are in place.
The authors have made their case and they want the attention of HHS and Xavier Becerra.
The NASEM committee highlighted the importance of creating an implementation plan and establishing a secretary’s council on primary care, which would be responsible for coordinating the federal government’s work in this area and for “aligning private-sector activities in support of primary care.
They outline what this HHS-created council on primary care would do. It is clear that after over a quarter-century of attempts at improvement through innovation and pay for performance schemes we have lost ground and that without some fundamental changes the future is bleak.
Among the most important elements for ensuring accountability are resources and outcome measures. The committee proposed that the council coordinate primary care investment throughout agencies “to ensure adequate budgetary expenditures” to accomplish implementation goals. The council could also establish accountability measures for a national “health of primary care” scorecard and track progress toward targets for each measure. Measures recommended by the committee include the percentage of total health spending going to primary care, the number of primary care physicians per 100,000 people in underserved areas, and the percentage of various clinicians working in primary care. The onus of achieving targets for these measures would fall on the government and private-sector stakeholders rather than on clinicians.
After recommending central coordination they give several examples of how this methodology has helped to ameliorate other problems. They also note that establishing a primary care coordinating council would not require an act of congress. Joe and Xavier, are you listening? Such a council would only be the first step, but it would be the formal recognition of a problem that will eventually affect us all. By the way, how easy is it for you, or for the people who use your system of care, to get an appointment in primary care these days?
Creating a council on primary care wouldn’t be sufficient to solve the problem of poorly supported primary care, but without such a concerted effort, the most important infrastructure available for advancing health equity will continue to erode. If a council focused on primary care had existed during the height of the Covid-19 pandemic in the United States, it could have helped rapidly mobilize primary care to address vaccine equity and shore up public health, particularly in rural and historically marginalized urban communities. Moving forward, we believe an infrastructure investment plan should include oversight, tools, and resources for rebuilding primary care, with clear accountability vested in a single council and an overarching goal of achieving health equity.
Up till now, I have resisted using my favorite quote from Dr. Ebert, the founder of Harvard Community Health Plan. In the mid-sixties, he could envision where we are now. More importantly, he gave us a view of where the solutions to current and future problems lay when he said:
The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.
The authors of this week’s article, “Revitalizing the U.S. Primary Care Infrastructure,” offer a path that is consistent with Dr. Ebert’s opinion. Finance methods are a big part of the current problem and need to change if primary care is to survive. Currently, we can not optimally staff the operating system for primary care that we have used for years. We have evolved more efficient practice models but they are not very widely implemented. It is also true that the optimal framework of primary care will not spontaneously evolve from a market-driven healthcare system. Like our energy infrastructure and national military defense, much of our healthcare system needs a coordinated national approach that guarantees attention to populations that are underserved. What is startling is the fact that as the world gets hotter and we all suffer it is also quite possible that most of us will eventually suffer from inadequate primary care. I hope the Secretary of Health and Human Services or somebody near to him reads the New England Journal of Medicine.
Fall Is Looking Good
I am expecting to have a ball this fall. I kicked off the fall season last weekend in beautiful Brunswick, Maine. I was there to watch my granddaughter play in her first college volleyball game for the Bowdoin College Polar Bears. Bowdoin played Wesleyan on Friday evening and Connecticut College on Saturday afternoon. They won both matches. We are headed back this weekend to see Bowdoin play Tufts and Maine Maritime. What is even better is that one of my wife’s dearest friends since nursing school lives with her husband just three miles from Bowdoin in Topsham, Maine. We will enjoy seeing them frequently over the next few years.
This week’s header was taken last Sunday morning on the Androscoggin River Bicycle Path which is a little bit of a misnomer since it also has a walking lane. Our friends introduced us to the trail on a previous visit a few years ago and it was great to visit it again. I was delighted to be able to walk three miles without pain with my recently adjusted foot drop brace. I am looking forward to checking out the transition of the color of the trees along the banks of the Androscoggin from green to glorious fall colors of red, yellow, and orange over the next several weeks as I return for more volleyball games.
I believe that the “secret to good health” is to have something to do, something to anticipate, and people to love. I am all set because I score on all three points! I hope that you are anticipating good health and proximate happiness because with a little effort you too can score in all three of the “secret to good health” categories.
Be well,
Gene
