Wednesday, February 22, 2017

Advanced primary care vs (or is?) direct primary care

One of my most popular Twitter retweets this month highlighted a graphic from the Wall Street Journal showing that in 2014, middle-income households spent 25 percent more on health care than they did in 2007, but 6 to 18 percent less on other basic needs such as housing, transportation, food, and clothing. I commented: Too much of HC debate about "who pays"; not enough questioning "why does HC cost so much?"

One good answer is that lots of health "care" is worthless or harmful, but incentives baked into the U.S. health system push doctors to provide (and be paid handsomely for) it anyway. Shannon Brownlee first told this story in her book Overtreated (and revisited it in this recent review for The Lancet); Atul Gawande described unnecessary medical care as an "avalanche" in his New Yorker profile "Overkill"; and David Epstein called it an "epidemic" in his Atlantic article "When Evidence Says No, but Doctors Say Yes." The bottom line: instead of improving health, many medical interactions are merely opportunities for something bad to happen. (For a timely example, see this NPR article about the harms of screening for cardiac disease in teenage athletes.)

Doctors generally aren't paid to provide quality health care rather than more health care (quantity). A more catchy phrase for this idea among health policy wonks is "moving from volume to value." After more than a decade of trying, mostly unsuccessfully, to cut doctors' fees to compensate for steady increases in the volume of health care services, Congress passed legislation that empowered the Center for Medicare and Medicaid Services to create a quality payment program. Physicians can enroll in one of two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

In December, the American Academy of Family Physicians published an 11-page position paper that proposed an APM called "Advanced Primary Care." My friend and fellow family physician Richard Young has been dissecting the nitty-gritty details of the proposal in a series of posts on his blog, here, here, and here. It's clear to me that some smart people at the AAFP invested a great deal of time and energy into its development, addressing thorny issues such as how to adjust for social risk factors that make even the best physicians' quality measures look bad and could, if not taken into account, have the unintended effect of reducing access to health care for those who need it the most. It's also extremely complicated, and I have no idea if it would improve quality or lower costs.

Family physician-turned-financial planner and Forbes blogger Carolyn McClanahan has been arguing that a simpler strategy for reducing the nation's health care bills that doesn't involve rationing care for the poor is to remove primary care services from health insurance entirely. This is a strategy that direct primary care advocates have championed; by eliminating administrative burdens and inflated charges for low-cost services, it results in unhurried in-person visits, more flexibility to provide care by phone or electronic communications, and truly personalized care. But McClanahan added a new twist: make basic primary care free to all by giving community health centers enough funding and capacity to provide services to every American who desires it. (Those who would still prefer to see a private family doctor could presumably pay a monthly fee to be part of a direct primary care practice.) Her plan is worth a long look: you can read an abridged version on or a more detailed proposal here.

Although it's been hard for me to see much upside to the Trump presidency, revisiting the Affordable Care Act doesn't need to be bad news. A Hillary Clinton presidency and a Republican-controlled Congress would have likely resulted in continued stalemate: no ACA repeal, but no forward progress in repairing its significant flaws, either. Instead, the political impetus to imagine something better than the health system status quo may galvanize positive change. Family medicine leaders can continue to tinker on the margins, developing iterative proposals for "advanced" primary care that won't make our specialty any more appealing to medical students than the 2004 Future of Family Medicine project or the 2013 Family Medicine for America's Health initiative did. Or they can choose to commit fully to a vision of a health system where everyone has a family doctor, that doctor doesn't change when health insurance changes, and "advanced" primary care means direct primary care.