If you have avoided these notes for the past few weeks, you may not know that I have been systematically reviewing the recommendations of the Commonwealth Fund’s Task Force On Payment and Delivery System Reform. There are six sections to the report. So far we have reviewed “Increase Health System Preparedness” and “Increase Health System Accountability.” The third of the six recommendations of the task force is to “Strengthen Primary Care.”
This section begins:
Comprehensive, coordinated, continuous, longitudinal, and first-contact primary care is not only the foundation of a high-performing health system but a critical complement to accelerated value-based payment. In fact, decades of rigorous research show that robust primary care is associated with better health outcomes, greater equity, and lower health care costs per person. Yet the U.S. primary care system often falls short, especially for people of color, individuals with low income, rural residents, and women. The supply and availability of primary care clinicians are inadequate for the need, and too many are inadequately compensated, overworked, and deeply stressed. Moreover, primary care is frequently unavailable to Americans after working hours, resulting in unnecessary use of emergency room services. The COVID-19 pandemic has further caused massive disruptions in health care, placing greater financial pressure on already strained primary care practices.
Once again let me reference Dr. Robert Ebert. In October of 1967 just a few weeks after I had entered Harvard Medical School, he probably walked a few hundred yards down the Avenue Louis Pasteur to the campus of Simons College which sits at the corner of Louis Pasteur and the Fenway Parkway overlooking a little piece of Frederick Law Olmstead’s Emerald Necklace. He then proceeded to deliver “The Kate McMahon Lecture” which is an excellent snapshot of the status of healthcare in 1967. The main focus of Dr. Ebert’s analysis was the plight of the urban and rural poor and how the system of care was failing them. He touched on the overemphasis of specialty care and advocated for a refocused emphasis on primary care. That was fifty-four years ago. I first read Dr. Ebert’s analysis in 2008 although I had heard many of the same points discussed as a contemporary problem many times over the previous thirty years.
I’ve always liked the way he ends the first paragraph because it is a snapshot of the subjective feelings that many people continue to have about doctors.
A cursory survey of what has been written in newspapers, as well as weekly and monthly magazines, permits the conclusion that medical science comes off rather well and the doctor’s image not so well. One gains the impression that doctors as a group is motivated by money, are becoming less and less interested in patients as people, and are socially irresponsible.
More often than not an author will point out that his own doctor is a good fellow but that the remainder of the profession is grasping, money-hungry, and dehumanized…
Very quickly Dr. Ebert explains his observation:
The public has been indoctrinated to believe in the miracles of modern medical science, but the reality of delivery falls short of the expectation. The doctor is uneasy because his traditional role seems to be changing. He can no longer act solely as an individual, for he has become increasingly dependent upon others — other doctors, others in the health field, and above all upon the many people who work in the hospital. This changing role is related to his changing social responsibility.
His explanation goes on to include that many doctors are socially responsible and offer pro bono care while teaching without much compensation. My early implication that nothing has changed was wrong in part. We now have “bad debt,” but it has been a while since I have heard a physician, medical group, or hospital system talk about the pro bono or charity care that they offer unless they are challenged to defend their non-profit status. I am not complaining about the fading reality of charity care because I don’t believe the answer to our current deficiencies in care delivery is to reinstitute pro bono practice. I much prefer the dignity of universal access to care as an entitlement that is owed to every person in our society. Dr. Ebert continues his review of the status quo in 1967 by saying:
The result is a more specialized and a more fragmented kind of medical care, often with no one coordinating the total care for the individual, much less the family.
Once Dr. Ebert had established realities that his audience knew to be true based on their own interactions with the fragmented system of care that had evolved as medicine was more and more focused on what science could offer and less focused on the patient, the family, and the needs of the community he made a remarkable statement:
There is no lack of problems to preoccupy the physicians who wish satisfaction from personal involvement in the health field. In my opinion the social problems are of greater magnitude than those which are strictly medical. Not only is there a place for the physician in the approach to these problems but he must be involved if they are to be solved. Let me describe what I believe to be some of the pressing social issues that involve the medical profession.
[I should note here that the pronoun “he” is revealing. Even in 1967, less than 15% in my class were women. There were two Black students and one Asian American.]
The breadth and depth of Dr. Ebert’s analysis and understanding of the state of healthcare in 1967 are more than matched by his compassion for the underserved among us.
Closely linked to the evolution of the modern hospital is the problem of the distribution of medical care. There are two groups who have suffered from the changing pattern of medical practice: the rural population and the urban population occupying the central city. Both groups present special problems, and both require new approaches to solutions. Most of you are familiar with the problem of the rural community. Here the general practitioner is the mainstay of the medical care system…
The problems of the urban poor could be easily observed by walking less than half a mile in any direction from the corner of Fenway and Louis Pasteur where he was giving his speech. Any outfielder for the Red Sox could throw a baseball from the front steps of the nearby Peter Bent Brigham Hospital and hit the home of someone who matched the definition of “urban poor.” In fact, these people were frequently valued as “teaching” cases.
Dr. Ebert closed his speech by advocating for continuing innovation in the coordination of care through an emphasis on primary care. He placed great emphasis on the importance of developing programs within the medical curriculum that produced an increasing number of young doctors that had a robust understanding of their social responsibilities.
Much more needs to be done. More able people are needed in the medical school environment who devote their attention to the social problems of medicine. There must be study of the needs of particular communities, and innovative plans introduced by the teaching hospital to test new ways of organizing medical care. There must be a greater integration of effort of physicians, social workers, nurses and others, both in the hospital and in the community.
Above all, the student must actively participate in such programs. He can learn from lectures and seminars but he must experience a new kind of social responsibility within the clinic if he is to be influenced in the future.
Exactly two years after the speech Harvard Community Health Plan opened its doors on the other side of the Fenway about a half a mile away. It was a multispecialty group practice designed to use innovation to improve the quality of primary care delivered by teams that included advanced practice clinicians to provide more immediate access and working in close collaboration with colocated specialists. Over the next fifty years, this practice would be a leader in the evolution of primary care innovations that were designed to advance the Triple Aim and improve the social determinants of health.
This was the world I saw evolving as I spent my time in medical school, and completed a medical residency and fellowship in cardiology at the Brigham during which I also began to work part-time in the HCHP practice. In 1975 all of the medical specialists at HCHP also had primary care practices. It was a perfect fit for me since my motivation to do a cardiology fellowship was that I thought being a cardiologist would make me a better primary care physician.
Let’s go back to the first sentence of the primary care recommendation of the task force. It immediately connected primary care to payment reform:
Comprehensive, coordinated, continuous, longitudinal, and first-contact primary care is not only the foundation of a high-performing health system but a critical complement to accelerated value-based payment.
The original HCHP was exclusively meant for prepaid patients. Initially, the care of the urban poor was supported through grants. Since Romneycare passed in 2006 more than 98% of the citizens of Massachusetts have had access to care. Social status was never a barrier to care in our offices. Equity was not a stated goal but it was a by-product of the practice’s quality objectives and its value-based system of finance. Perhaps one of my fondest memories of my years at HCHP was of a day in the late 80s when I looked into the waiting room for my next patient, an African American man with a dilated cardiomyopathy who was still struggling to continue to work as a toll taker on the Mass Pike, and saw him sitting next to our governor who was waiting for his appointment with one of my colleagues. That is a picture of healthcare equity that I will never forget.
The task force envisions an outcome that is consistent with the objectives that were the vision of the practice that evolved from Dr. Ebert’s concepts:
The Task Force aims to strengthen and modernize primary care in the U.S. so that it meets the health needs of patients, from prevention and chronic disease management to behavioral health and social services. Our vision for primary care in the 21st century is not limited to the traditional clinician’s office, nor is it focused exclusively on the physician. Like the rest of our health care system, the primary care sector needs to innovate — for example, by using multidisciplinary care teams and digital health tools to promote sustained relationships between clinicians and patients.
The picture in today’s header is of a primary care team at the Copley Square offices of Harvard Vanguard taken at least a dozen years ago. That office sits over the Mass Turnpike. On the north side of the Pike, in affluent Back Bay, ZIP codes 02214-02217 plus 02199 and 02228, the life expectancy is greater than ninety years. To the south is Roxbury with ZIP codes 02218-02220 plus 02225 where the population is poor and the life expectancy is between 58 and 59 years. It’s another example of the fact that it is your ZIP code more than your genetic code that defines your healthcare risks in America and around the world. The team in the picture functions as a “medical home.” It is diverse. Every team member plays a meaningful role and participates in the satisfaction of their collective effort. These days they offer many patient “touches.” They offer care in person, by phone, by discontinuous messaging, by email, and by telehealth technology. There are case conferences and team huddles to facilitate care and eliminate waste.
The task force offers three broad suggestions with multiple recommendations under each topic. The three categories are:
- Improve Quality and Comprehensiveness of Care Through Payment Reform
- Expand Supply, Diversity, and Increase Retention of Primary Care Clinicians, Particularly in Underserved Communities
- Promote Use of Telemedicine for Primary Care
Each broad topic has several items under it. As in other sections of the task force recommendations, many of the suggestions begin with “Congress should…” Making those happen will probably require doing away with the filibuster. The most articulate advocate that I have heard for why this should happen is Ezra Klein who now writes and offers podcasts from the New York Times. The previous link is to an article Klein wrote for Vox. He has just released an excellent podcast for the NYT making the same arguments.
The real possibilities for policy changes exist when the recommendation leads with “CMS should…” It is a reality that CMS can drive extensive positive change that will be reflected by commercial insurers. I sense that there are insurers and employers that purchase care from them that would be delighted for CMS to push them toward more value-based offerings.
As I review the suggestions, I see that all of the task forces recommendations begin with either Congress, Congress with HHS, or CMS changing some circumstance or rule related to finance. Despite that reality, there is much that healthcare could choose to do on its own. The work that Dr. Ebert initiated comes to mind, as does much of the work that has occurred at places that I have discussed in previous posts like Kaiser, Virginia Mason, Denver Health, Iora, and ThedaCare. Zeev Neuwirth regularly presents the work of innovators in primary care in his podcasts. Federal programs and new laws from Congress can make a big difference in creating an opportunity for better primary care that makes healthcare better, but those efforts will go much further toward the goals of better care for everyone, healthier communities, and the control of costs–the Triple Aim– if we accept that those efforts will require self-starting physicians and health systems that focus on defining and acting with a greater focus on manifesting their social responsibility through their improved efforts in Primary Care.
