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Curbside Consult with Dr. Jayne 6/7/21

June 7, 2021 Dr. Jayne 6 Comments

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.

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Currently there are "6 comments" on this Article:

  1. It’s rare that I read articles that I totally agree with but this is 1000% on the mark. The supply chain for primary care needs to be fixed and that won’t happen unless and until reimbursement incentives are adjusted. In our area, which is suburban and had plenty of physicians, it’s still a many month wait to see a primary care physician. As a result people avoid getting one and end up at urgent care. Medical school loans are astronomical for those who are just graduating and primary care reimbursement makes it challenging to pay off loans. Primary care physicians are expected to take care of everything in a 15 minute visit and it just can’t be done. The whole RVU system and assignment of charges to CPT codes has been broken for years and the burdens imposed by insurers for preauthorizations, etc have disproportionately fallen on primary care clinicians since surgical specialists make enough money to hire someone else to do the work. Getting rid of these ridiculous time consuming and frustrating barriers would improve matters for all, including patients. We definitely need to stop getting distracted by the latest “shiny object” and focus on actual patient needs. I’m looking forward to reading the rest of the NAM report!

  2. I’m going to be controversial here, so get ready.

    “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.”

    It seems to me that this is both right (on the surface) and wrong (in subtext). I mean, what is much about this article is about? If we are being completely honest, it’s about, ‘How do we make the field of Medicine more attractive to Clinicians’.

    And all of that adds up to going back in time. Society has already chosen, and mostly, Society doesn’t care.

    Instead, this is, in my opinion, what we need to change:

    1). Medicine needs to become cheaper, or at the very least, more cost-efficient;
    2). We need more certain outcomes. There are endless studies that hint, or outright say, that there are outcome variations that can only be explained by local practice patterns;
    3). We need Medicine to be evidence-based (the current system is pretty good at this, with only occasional problems IMO);
    4). Patients need more input into their courses of care;

    Here’s another contentious idea. Points #3 & 4 are going to conflict, and often enough to be a problem. You won’t see too many Physicians prescribing courses of laetrile or crystal therapies. I predict though, that lots of patients will ask for these. Indeed, they likely are already doing them.

    The technology is merely a means to an end. My theory? We actually aren’t far enough down the adoption curve yet. Things like EMR workflows, interoperability, all the hot topics. Those are tactical problems that will yield to sustained efforts in time.

    Look at the automobile. Early cars were terrible! You’d have been better off, unless you were obsessed or a hobbyist, to stick to horses. The rules of the road also took years to implement and make the whole system work better.

    Look at old newsreel footage from any major city. The streets were chaos, with pedestrians, streetcars, cars, dogs, horses, all at different speeds and moving in different directions.

  3. An excellent piece, breaking more than a few icons and goring an ox or two as well. Thanks!

    One of the truisms I was told a long time ago by family medicine founding fathers is that primary care has always failed to compete adequately in the American way of doing things. Our commitment to patient care — our mensch-like attitudes to do good on local scales one case at a time, coupled with our lower incomes has kept primary care physicians from putting the same amount of money and time resources into changing the system as our specialist colleagues. That has only been exacerbated by the lobbying dollars of the pharmaceutical and insurance firms along with the large organized health care industry in general to take advantage of primary care physicians as malleable, low-cost solutions.

    Bluntly put, while we are doing our quarterly CME questions for our 2.5 points, thereby allowing our leaders to justify their latest layer of obfuscation without real change, we could have been communicating and networking with others.

    It will be noteworthy if change occurs at this stage to finally recognize technology applied well depends upon high-quality primary care services which in turn requires a huge paradigm shift as to who owns and controls the information flows.

    American lives depend up on it.

  4. A point from mr histalk’s article comes to mind. From a medical output standpoint, the most productive primary care practices probably have less than five providers. Technology provides little to no benefit. Practices get larger so that they can negotiate with insurance. The dynamics are different for single and multi speciality and hospital owned of course.

    We shouldn’t raise the compensation for primary care. We shouldn’t raise the compensation for anyone in medicine. We should lower barriers so that there is more competition.

  5. You are 100% on the mark yet fighting the lobbying power/dollars of specialties, hospitals and big tech.
    Kudos for speaking out.

  6. Interesting article and an interesting report.

    I do worry about the monetization of the healthcare and the drive for young practitioners to get the best specialty. Some, I am sure are just drawn to that specialty, others are drawn to the compensation. The monetization goes up and down the stack, from VCs purchasing rural hospitals so they can overcharge for labs, to purchasers of EHRs so they can overcharge the clinics, to hospital administrators who have forgotten that a hospital is for patient care, not for generating an insurance bill or funding a collections company. We could look at the pharmaceutical industry, where ramping up the cost of essential drugs is seen as a good business practice (Epi Pen?) or fighting going to an over-border pharmacy because Canadian Jardiance/Januvia costs $2.00/3.00 a pill instead of $40 per pill (they did recently cut their price in half but…) in the states.

    That worry translates to the recommendation that reimbursement rates rise by 50% — once that happens more companies will see primary care as a profit center instead of a front line prevention opportunity. I mean, you can look at the health care systems of all those third world countries: England, EU, Japan, Korea, Canada as prime examples of how bad it could get when you don’t have a for profit health system (sarcasm font in full bold).

    I would definitely like to see more emphasis on research at the primary care level and more clinicians trained in research, but if you are doing pajama charting then you really don’t have time for the discipline of research.

    Lastly, if our technology is not incentivized to generate research data then our wisdom will be diswise. The two bad classes of data quality (WTF and “I think it might mean this but…”) are driven by four different causalities: Self, vendor, institutionally, and externally inflicted. The vendors need to do a better job of helping the clinician do the right thing, and not do the wrong thing — Medication Allergies in Problems or Medication Allergies written in notes — because clinicians didn’t go to school to become computer scientists. Institutions need to understand that configurations matter, and malalignment with standard configurations (enumerations, dictionaries, or code sets) will have an impact. That when we create regulations those regulations have an impact of performance — tell me how you rate me and I will tell you how I perform. These causalities are getting in the way of moving data to wisdom

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