"Still, there’s often confusion about who is caring for the patient ... " Playing off of Jimmy the Greek's comment,…
Last month, the National Academies of Sciences, Engineering, and Medicine released their report on high-quality primary care for US residents. The National Academies are private, non-profit organizations formed with the goals of informing US public policy and providing independent analysis and advice. After spending a couple of decades in academic medical centers and integrated healthcare delivery networks, I have a greater degree of trust for independent analysis compared to some of the output I’ve seen from “not-for-profit” organizations that have billions of dollars in the bank.
The report is titled “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” The Academies’ press release is quick to note that “no federal agency currently has oversight of primary care, and no dedicated research funding is available. The report recommends the US Department of Health and Human Services (HHS) establish a Secretary’s Council on Primary Care and make it the accountable entity for primary care, as well as an Office of Primary Care Research at the National Institutions of Health (NIH).”
The report outlines a plan where patients should be able to have consistent primary care and that they should declare their primary care provider annually so that payers can ensure accountability and quality measures. This sounds similar to what I experienced on a rotation in the United Kingdom many years ago, where patients were expected to “register” with their general practitioner so that they would have a source of care if they needed it. This is very different than some of the consumer-oriented models of care that are booming in the US, where healthcare has become purely transactional, and many patients value convenience above all else. The decline in primary care availability over the last several decades has fueled growth in urgent care and retail clinics, and patients no longer see continuity or having a relationship with a primary care provider as something important.
In my experience, that erosion of respect and responsibility has contributed to a decrease in the number of students who want to go into primary care fields. Compensation is another big factor, and the report recognizes that as well, calling on more equitable compensation for primary physicians as compared to subspecialty care. There’s still a perception in the US that the best and brightest medical students go to the high-dollar subspecialties. As I sat doing my quarterly board certification questions tonight (which were quite difficult), it made me reflect on how much better it would be if the best and brightest were drawn to primary care, where they could solve diagnostic dilemmas firsthand rather than having to refer those cases out or potentially order tens of thousands of dollars in diagnostic testing.
The report notes that primary care practices were initially left out of COVID-19 relief packages and that they have not been fully utilized in support of testing, contact tracing, and vaccination efforts. It suggests that pandemic-related changes should become permanent, including coverage for telehealth services and reductions in documentation requirements.
I was intrigued by some of the suggestions made by the committee. One was that CMS should increase physician payments for primary care services by 50%. For practices struggling with a razor-thin margin, that would be a good start. Even better would be if non-CMS payers followed suit or increased their rates even higher than 50%. Another recommendation would be that CMS identify overpriced healthcare services and reduce the rates on those services to make them less attractive. I’m sure professional groups and vendors will oppose that, though, depending on whose cash cow might be in line for the sacrifice.
One of the major things that goes unsaid in the report is the massive culture change needed in US healthcare. We need to shift from a culture that venerates technology for the sake of technology to one that venerates knowledge and wisdom, with the appropriate and judicious use of technology as appropriate. Patients have grown to equate high-tech care with high-quality care, even when studies show that the technology is not helpful. I’ve seen dozens of patients come to urgent care hoping we will order advanced imaging studies, such as MRI scans, where they’re clearly not indicated, because patients feel like having an MRI will give them an easy answer. Why do four to six weeks of physical therapy and conservative management to see if your problem gets better when you can just have an MRI?
The needed culture change also applies to pharmaceuticals. We have to make some of the best initial treatments, like diet and exercise, more attractive than just popping a probably-expensive pill. This is a place where technology might really give us a boost, if we can use gamification and people’s inherent competitive natures to spur them to action. Technology can help give positive reinforcement and provide interventions and coaching that patients may not have had access to without it. Attitudes towards non-pharmaceutical interventions aren’t going to change overnight, though.
The committee also calls on leadership to use digital technology to make primary care more efficient, higher quality, and more convenient. It calls on the Office of the National Coordinator for Health Information Technology to address clinician user experience part of the next set of certification requirements.
A big piece of efficient data management though isn’t going to be the user interface of individual systems – it’s going to be addressing once and for all the absurd level of information blocking that goes on between health systems in the same city. As an independent urgent care physician, I could not get a single one of the four health systems in town to grant me access to their systems for “refer and follow” data access, regardless of how many patients I sent them or how many of their patients I cared for when their own physicians were unable to see them. I wish I had a fraction of the dollars I wasted ordering duplicate tests because I didn’t have full access to my patients’ health records.
I don’t think that anyone disputes the idea that a strong primary care infrastructure would not only improve people’s health and save lives, but would save our country a tremendous amount of money. Other nations (whether wealthy industrialized ones or middle-tier countries) have seen this value and have constructed their healthcare systems accordingly, while we have constructed ours around special interests, shareholders, and profit. According to the Organization for Economic Cooperation and Development, 5% of US health spending goes to primary care compared to 14% in other wealthy nations.
Although I started my career in the primary care trenches, I struggle to encourage medical students to follow that path unless they have a full understanding of the current state of things. I enjoy focusing my informatics work on trying to strengthen technologies that support primary care, but it’s going to take a lot more than bells and whistles to truly make it an attractive career again. As the pandemic eases, we’ll have to see what governmental entities have to say about the recommendations in the report, and how many decades it might take to make them a reality.
What do you think about the need to rejuvenate primary care? Will culture continue to dominate regardless of how much technology we try to throw at it? Or will we just watch history repeat itself? Leave a comment or email me.
Email Dr. Jayne.