Primary Care as Healthcare Infrastructure

Wanda D. Filer

The need to rehabilitate American infrastructure such as roads, bridges, and water systems is well recognized. These services are used daily by millions and impact the economy, health, and commerce of America. Likewise, primary care needs rehabilitation, investment, and much more public policy attention. Patients with high cost chronic conditions are more likely to see a primary care physician than a specialist physician. ¹ The complexity of these visits continues to be under recognized and undervalued, endangering the health of the patient and the economic health of this nation.

It has been ten years since Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicaid services, promoted the concept of the Triple Aim, with obtainable goals of a) improving the patient healthcare experience, b) improving the health of the population writ large, and c) reducing costs. Local efforts have had some impact, although progress is uneven. Frameworks for achieving these objectives are still being implemented with more work to be done.³ Stressors on the primary care medical community are extremely high, with complexity of care for each patient typically exceeding that of many other specialties such as cardiology and psychiatry.² Primary care is tasked with managing the multitude of chronic diseases encountered everyday in most patients on a background platform of prevention, wellness, and personal counseling. The addition of population health has all too often been met by adding to workload without adequate technologic tools or human resources, nor payment to accomplish these critical goals. Indeed, burnout across medicine has led to the newer use of the Quadruple Aim with a goal of d) improved work life balance in medicine careers.⁴

According to the 2013 National Ambulatory Care Medical Care Survey, an estimated 210 million patient visits are being performed each year in Family Medicine, 125 million in general internal medicine, and 102 million in pediatrics (the three medical specialty groups who traditionally comprise primary care) among the total number of physician visits at 922.5 million.⁵ In Family Medicine practices, it is very common for patients and their clinicians to deal with 5-10 different chronic conditions, adding a layer of intense complexity that is typically not understood in policy worlds.

The value of having a usual source of care (continuity of care) who understands the patients’ wishes, history and challenges, cannot be underestimated if we are to improve patient outcomes. The human relationship between a patient facing immense health concerns and a clinician who knows the patient well can reduce hospitalizations, improve medication adherence, and improve uptake of vital preventive services such as flu and pneumococcal immunization, colon cancer screens, and depression counseling. These relationships also improve both the patient’s and the clinician’s satisfaction. Having more face-to-face time with each patient, especially those patients that have a complex range of conditions, can have a significant positive return on investment in both human and economic terms. With current predominant payment schemas of fee-for-service and low payment rates, longer visits do not often allow practice financial viability. Realigning payment incentives and strategies to promote longer face-to face time is urgently needed. Value based payment needs to consider this metric.

It has become clear that the success of a country’s healthcare system is directly tied to its support of primary care and the U.S. is failing in this regard. Indeed, the Commonwealth Fund, in its latest 2017 rankings of Health Care System Rankings across 11 developed nations once again ranks the U.S. dead last.⁶ Those countries that perform better typically prioritize primary healthcare, spending a larger percentage of their healthcare dollar on these services than the problematic U.S. pattern of downstream spending. With the U.S. spending on healthcare now approaching 19% of our GDP, vastly more per capita than better performing nations, it is time for a pivotal change.⁷

Healthcare, as currently funded and prioritized, is bankrupting the U.S. economy while continuing to deliver failing results. Reducing the GDP portion spent on healthcare would allow more spending on education, housing, food security, and other important social determinants of health that have a greater impact on the health of our population than the dollars spent on healthcare. Reallocating the healthcare spending to place an emphasis on primary care can also have a major impact on performance.^8,9 Instead of the paltry single digit of each healthcare dollar spent on primary care, increasing the spending to 12-20% can save lives and dollars. Some states are already undertaking these initiatives and it will take time to see results, although early impacts are promising.^10,11 Reallocating away from high cost and overutilized imaging/testing of questionable impact can also be a source of funds to improve the primary care spending.¹²

Recognizing that current payment models such as high deductible health plans (HDHP) have had the unintended consequence of delaying needed primary care, when a condition is still amenable to treatment, needs consideration. A primary care carve out for these HDHP is likely a more cost effective solution. Projects underway across medicine such as Choosing Wisely, are strongly planted in primary care and though they address unnecessary, wasteful, and potentially harmful care¹³, they could benefit from strong health policy support and awareness. Increasing the percentage of medical school graduates who choose primary care, critically measured 5 years from the graduation date, can improve workforce shortages. Holding medical schools accountable for meeting the health workforce needs of this nation is another opportunity for improvement. Medical student debt burden, admission processes, and common medical school culture of very negative attitudes about primary care as a career choice deserve robust attention.¹⁴

If we understand primary care as critical infrastructure, something used by millions daily that impacts the economic vitality of the country, it is easier to grasp why new investment in better payment for service, attention to improved workforce development, workflow redesign, and technological innovation is needed. Ignoring primary care is a recipe for continued poor healthcare performance, wasted resources, and missed opportunities. We can and must do better! Our citizen’s lives and the wellbeing of this nation hang in the balance.

About the Author

Dr. Wanda Filer MD MBA FAAFP, is Past President (2015-16) and Board Chair (16-17) of the American Academy of Family Physicians. She sees patients at Family First Health, a federally qualified health center in Pennsylvania. She is a healthcare consultant, founder of the Strategic Health Institute, with special emphasis on public health initiatives and health policy. She also served as the first Physician General of Pennsylvania.

References

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2. Katerndahl D, Wood R, Jaén CR. Family medicine outpatient encounters are more complex than those of cardiology and psychiatry. J Am Board Fam Med. 2011;24(1):6–15.

3. Q&A: Niñon Lewis on the 'Triple Aim' of Health Care [Internet]. U.S. News & World Report. U.S. News & World Report. Available from: https://www.usnews.com/news/healthiest-communities/articles/2018-05-25/a-decade-later-triple-aim-health-care-framework-offers-lessons-promise

4. Bodenheimer T. Thomas Bodenheimer [Internet]. The Annals of Family Medicine. Available from: http://www.annfammed.org/content/12/6/573.full

5. National Ambulatory Medical Care Survey: 2013 State and National Summary Tables.

6. Health Care System Performance Rankings [Internet]. Commonwealth Fund.]. Available from: https://www.commonwealthfund.org/chart/2017/health-care-system-performance-rankings

7. NationalHealthAccountsHistorical [Internet]. CMS.gov Centers for Medicare & Medicaid Services. 2018. Available from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

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9. Disinvesting In Primary Care? [Internet]. The Physician Payments Sunshine Act. Available from: https://www.healthaffairs.org/do/10.1377/hblog20180309.891876/full/

10. Measuring Primary Care Health Care Spending | Milbank Memorial Fund [Internet]. Emerging and Re-emerging Infectious Diseases: 2018. Available from: https://www.milbank.org/2017/07/getting-primary-care-oriented-measuring-primary-care-spending/

11. The Commonwealth Fund - 2018 Scorecard on State Health System Performance [Internet]. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. Available from: https://interactives.commonwealthfund.org/2018/state-scorecard/

12. JAMA: U.S. spends the most on healthcare-and imaging is a reason why [Internet]. Health Imaging. 2018. Available from: https://www.healthimaging.com/topics/practice-management/jama-us-spends-most-healthcare-and-imaging-reason-why

13. American Academy of Family Physicians [Internet]. Choosing Wisely – Promoting conversations between providers and patients. Available from: http://www.choosingwisely.org/societies/american-academy-of-family-physicians/

14. Aligning Resources, Increasing Accountability, and Delivering a Primary Care Physician Workforce for America. 2014.