There is widespread agreement that the United States must expand and improve primary care in order to achieve better health outcomes at a lower cost. A report from the National Academies of Sciences, Engineering, and Medicine (NASEM) published last May concluded that primary care is the only medical discipline where a greater supply produces improvements in population health, longer lives, and greater health equity. This growing consensus is a good thing.
But current efforts to wring “value” from primary care by focusing on diagnostic algorithms and quality metrics reveal fundamental misunderstandings of primary care’s purpose. The attempts to apply processes and technology designed for subspecialty care to the delivery of primary care have proven insufficient to support the complex work of the primary care team.
Primary care is unique in health care. It cannot be managed the same way as other parts of health care where the emphasis has rightly been on streamlining and cutting waste from a bloated system. At the heart of primary care’s success remains a unique relationship between physicians and patients built on trust.
For centuries, medicine was more relationship than science. The invention of the stethoscope, and then antibiotics, began to add more tools to the doctor’s bag and pushed medicine toward becoming a more stoic science.
Primary Care Doctors Are Not Subspecialists
Today, subspecialty care is rich with sophisticated tools. Subspecialists excel at diagnostic and therapeutic interventions, delivering complex treatments and procedures — fair territory for the use of checklists, documentation templates, and the measurement of specific processes tied to limited outcomes. While these things are certainly valuable for surgeries and ongoing cancer care, primary care specifically demands approaches that require dynamic systems of support. For primary care, the conversation with the patient, the longitudinal relationship, and the whole-person approach are necessary to achieving results that impact outcomes and costs. Overly concentrating primary care — through policy, payment mechanisms, and infrastructure design — on distinct processes tied to metrics diminishes the powerful role that the patient’s relationship with their primary care physician should play in health care.
The scope of primary care is as broad and as deep as the human experience. Primary care interactions, more so than in any other discipline of medicine, cover a vast territory. Both physician and patient bring an agenda, and conversations often become tangential and circle back. Attempts to make this interaction more “efficient” through technology and processes superimpose artificiality and rob the physician of the very responsibilities they are trained for — to build a bond of trust and ultimately influence healthier, life-giving behavior. Listening to the patient and then developing together with the patient an effective plan of care is why NASEM reached the conclusion it did.
Consider this patient encounter. A patient schedules an appointment for evaluation of low-back pain. At the appointment, the physician delves into the electronic health record (EHR), clicking boxes in a template designed for the symptom of back pain. The physician will rule out anything serious (infection, tumor, and so on), arrive at a diagnosis, and align this with the right billing code so that the documentation will meet billing standards. The patient leaves with a prescription for pain, perhaps an order for imaging, and the physician has ensured that the insurer will pay the bill.
Now consider an alternative scenario. A patient schedules an appointment with her personal primary care physician for evaluation of low-back pain. The physician explores with the patient the “why” behind the complaint. By taking the time to ask open-ended questions and actively listen (to a non-linear narrative), it is discovered that the patient has a sedentary job, has been experiencing high levels of stress and poor sleep, and has not been as active as she previously was — all surreptitious contributors to the symptom of low-back pain. In this scenario, the patient receives education about strategies to improve sleep, discusses with her physician ways to incorporate more physical activity into her life, and receives a referral to a physical therapist and recommendations about self-management techniques to help manage stress.
In the first scenario, it’s hard to determine who benefits. The insurer ends up paying for the wrong care, the patient is still stuck with no root cause and no real solution, and the physician gets paid but has a gnawing feeling that the encounter was a failure. Unfortunately, this scenario is all too common.
This is just one of many examples of how the health care industry has come to fetishize process-based health care for primary care physicians (PCPs), and how it is taking away (rather than providing) the tools they need to perform their jobs successfully. Checklists and templates may bring value for specific services, such as ordering a mammogram or administering vaccines. But the emphasis on discrete services and processes should not come at the expense of timely access to comprehensive longitudinal care with a physician you know and trust; we must not lose sight of the long-term outcomes in the quality and cost of care that should be the priority. In fact, I often joke that consciousness is a good place to draw the line: By all means use a checklist during surgery or in the ICU, but if your patients are awake and talking, listen to them.
Reinvent Primary Care
To truly empower primary care, we need to break the entire system that supports this robotic, process-driven approach. Here are three places to start:
Reform the payment model. America spends 50% less on primary care than any developed country, and it’s the one area that we know delivers actual cost savings with better results. We need to design a payment model that funds multidisciplinary primary care platforms accountable for achieving outcomes that matter with minimum requirements for process metrics and patient satisfaction baked in. This model should include predictable cash flow up front, in recognition of primary care as a common good in society.
Financial incentives should be tied to the unique qualities of primary care, which are linked to more high-value care, a better patient experience, a lower total cost of care, and longer life expectancy. Current metrics, designed by both government and commercial payers, trivialize primary care, and the associated reporting requirements strain practices and increase cost. The more powerful value in primary care is that which is tied to access to coordinated, whole-person care and a continuous relationship with a personal physician.
While various attempts to tinker with reimbursement models, ration care, insert gatekeeping, and reinvent the design of insurance plans have helped shift costs around, they haven’t improved outcomes or decreased the total cost of care. America has an opportunity to invest in primary care in a way that measures and incentivizes the true value of primary care, without stripping primary care doctors of their autonomy or burdening primary care with reductionist measures that are onerous and contribute to burnout. The emphasis should not be on rationing care; it needs to lean more heavily on delivering the care that patients need, which primary care physicians are uniquely positioned to provide.
Fix EHR technology. Incentives in the 2009 stimulus plan created a “big bang” for EHR technology, in which the federal government unwittingly subsidized thousands of “certified” systems that were already antiquated and were designed primarily to drive medical billing performance in a fee-for-service, subspecialty-driven landscape. Today, physicians across the United States are largely trapped in legacy technology entirely unprepared for a value-based, patient-relationship, collaborative-care future. Technology must be redesigned to be “clinical first” and integrate the entire health care ecosystem to make it easy to access and share information across systems. It must be purpose-built to remove barriers, unburden human effort, and create new capabilities while encouraging the best decision-making for patients, providers, and payers.
Change medical education. The vast majority of physicians complete their medical school and residency training in big hospitals that glamorize subspecialty and inpatient care, using EHR systems built around the billing process. It’s an indoctrination into the status quo of fee-for-service, subspecialty-driven sick care right from the start and paints a grim picture of primary care, which frightens away people who otherwise might choose to be PCPs. We need to expand medical training outside of big hospitals that exposes new physicians to community-based primary care designed to keep patients well. One positive step in that direction is the Teaching Health Center Graduate Medical Education Program. Created by the Affordable Care Act, it provides funding for residency programs in community health centers.
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.
