Wednesday, September 29, 2021

Like public health, primary care is in critical condition

The COVID-19 pandemic has exposed the negative consequences of two decades of neglecting public health at the local, state, and federal levels. After 9/11 and the following month's anthrax scare brought a temporary infusion of funds to public health departments to combat bioterrorism, the Great Recession of 2007-2009 resulted in deep budget cuts and layoffs that were never completely reversed. Even the Affordable Care Act's Prevention and Public Health Fund, a mandatory spending source for public health programs, was derided as a "slush fund" by opponents and repeatedly raided by both parties to pay for clinical initiatives such as launching the national insurance marketplace and avoiding cuts to Medicare physician payments. 

A less recognized but equally important problem is how a similar period of primary care neglect made the U.S. ill-prepared to deploy the most potent weapon we have against morbidity and mortality from the virus: three safe, effective vaccines. Mass vaccination events and making shots available in chain pharmacies were only ever going to take us so far. Since most vaccinations have historically been delivered by primary care physicians, failing to involve primary care organizations earlier in the vaccine rollout was a huge unforced error. Still largely reliant on fee-for-service payment models, primary care practices were battered financially during the early part of the pandemic when office visits plummeted. Although most family physicians weathered that storm, there aren't nearly enough of us in the first place. A recent study estimated that increasing the density of primary care physicians in U.S. counties with shortages could increase mean life expectancy by 56 days; increasing the supply of subspecialists, by contrast, doesn't extend life at all.

When she titled a recent editorial "Prioritizing Primary Care Can Save the U.S. Health Care System," Dr. Ada Stewart, President of the American Academy of Family Physicians, wasn't exaggerating. Even before last year's precipitous drop in life expectancy due to the pandemic, the U.S. already badly trailed most high-income countries. As Dr. Stewart wrote:

Our current system financially rewards individual health care transactions and financially penalizes long-term relationships between a patient and primary care team. It undervalues the essential care that occurs outside of the examination room. Benefit designs that place high cost-sharing requirements on patients, have onerous in-network and out-of-network rules, and rely heavily on utilization management make primary care less accessible for patients. Coupled with the crippling administrative functions placed on physicians and the low compensation rates for primary care services, we have a system that deemphasizes rather than prioritizes primary care.

There have been some promising efforts to finally prioritize primary care. A consensus report published this spring by the National Academy of Medicine declared that "primary care is a common good" and proposed five broad objectives that, if met, would dramatically improve population health:

1. Pay for primary care teams to care for people, not doctors to deliver services.

2. Ensure that high-quality primary care is available to every individual and family in every community.

3. Train primary care teams where people live and work.

4. Design information technology that serves the patient, family, and the interprofessional care team.

5. Ensure that high-quality primary care is implemented in the United States.

Reaching these objectives will require coordinated leadership from federal health agencies such as the Department of Health and Human Services, the Department of Veterans Affairs, the Health Resources and Services Administration, and the Office of the National Coordinator for Health Information Technology. It will require investments in primary care research from the Agency for Healthcare Research and Quality and the National Institutes of Health. And it will require reorienting a U.S. health care industry that isn't built for primary care to instead make primary care the fulcrum of a true health care system. As Elation Health CEO Kyna Fong wrote, "There has long been a sense that reinventing primary care is a key to fixing health care. This key hasn’t been working because we’ve been giving primary care doctors the wrong roles and measuring 'success' the wrong way. Primary care is uniquely positioned to explore the root cause of poor health and create a path to wellness. In order to do that, physicians need time to build relationships and trust with patients using tools to manage care in a complex and fragmented system. So many of health care’s problems could be solved if we started with that fundamental understanding."

Why am I - a career family physician who has never worked outside of the U.S., after all - so confident that boosting primary care is the answer to many, if not most, of our country's lagging health performance? Because other countries have already done it successfully. Dr. Atul Gawande described the latest example in his recent New Yorker article "The Costa Rica Model," where he observed that Costa Rica's average life expectancy is higher than that in the U.S. even though their per-capita income is a sixth of ours and the fraction they spend on health care even smaller. How do they manage to do this? After developing an outstanding public health system in the 1970s and 1980s, in the 1990s they combined their public health and medical care departments and assigned every single Costa Rican to a local primary care team (a doctor, a nurse, and a community health worker). In the U.S., by contrast, one-quarter of adults don't have a source of primary care. When these people get sick, they must seek care from a clinician they've never met and are unlikely to fully trust, whether it's in the emergency department, urgent care, or a random primary care office. And when they feel well, they don't have access to any of the preventive services that will help them stay well. That's a perfect recipe for living shorter, not longer.