Need Primary Care? Good Luck.

Last week’s post highlighted how fragmentation and lack of continuity could undermine quality and population health improvement. A comment from Mike Rawaan suggested two leading drivers behind the cost of care and poor outcomes:

• Misaligned incentives.
• Fragmentation of care (at the population health and episodic level).

I added three more (and invite you to add to the list in the Comments section):

• Underinvestment in primary care.
• The inability to differentiate (and adequately reward) better performance on quality, cost, and outcomes with the current state of accountability measures.
• Data inadequacy to support better measurement (i.e., completeness, accuracy, and usability).

Beyond Fragmentation...

As if fragmentation wasn't enough, limited access to primary care is pervasive, a fact highlighted in the recent report from the Milbank Memorial Fund , The Physicians Foundation , and The Robert Graham Center , “No One Can See You Now: Five Reasons Why Access to Primary Care Is Getting Worse (and What Needs to Change) .”

If you use your favorite GPT to highlight the most compelling statistics from the report, it will produce something like this:

1. The number of primary care physicians per capita has declined from 68.4 PCPs per 100,000 people in 2012 to 67.2 PCPs per 100,000 in 2021.
2. The total number of primary care clinicians (including NPs and PAs) per capita is increasing. However, it is still insufficient to meet the demands of overall population growth and an aging population with higher levels of chronic disease.
3. Only 15% of all physicians who enter residency training practice primary care three to five years after residency.
4. Primary care investment as a share of total healthcare spending has dropped from 5.4% in 2012 to 4.7% in 2021.
5. Since 2017, only around 0.3% of federal research funding per year has been invested in primary care research.
6. Technology has become an added burden to primary care, with over 40% of family physicians reporting poor usability of EHRs and one-quarter of family physicians being dissatisfied with their EHRs.

Elisabeth Rosenthal summarized the situation well in her September 2023 article entitled, "The Shrinking Number of Primary Care Physicians Is Reaching a Tipping Point ":

American physicians have been abandoning traditional primary care practice — internal and family medicine — in large numbers. Those who remain are working fewer hours. And fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients.

What Can Be Done?

The report from Milbank includes five objectives from the National Academies of Science, Engineering, and Medicine (NASEM) 2021 report entitled, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care ”:

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

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

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

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

5. Accountability: Ensure that high-quality primary care is delivered in the United States

The NASEM report includes very specific recommendations associated with each objective, including the following:

1. Shifting payment from fee-for-service to hybrid models.
2. Increasing the percentage of total health care spending to primary care.
3. Expanding the number of community health centers, lookalikes, school-based health centers, rural health clinics, and Indian Health Service facilities.
4. Support for integrated team-based care and equitable access to telephone and virtual encounters.
5. Funding for interprofessional training in community-based, primary care practice environments.
6. Modifying electronic health record certification programs to emphasize functions aligned with primary care and enhance usability.

While I believe better payment models for primary care are essential, they will not be effective unless they correct the historical underinvestment that has contributed to the current situation. Where will this funding come from? Estimates of waste in U.S. healthcare range from 25% to 30%. In U.S. dollars, that equates to between $760 billion and $935 billion (Shrank et al. in JAMA 2019). Of that amount, the authors estimated annual savings from a reduction in waste could be between $191 billion and $286 billion. Three areas for which enhanced access to high-quality primary care should be a significant driver of savings included:

• Failure of care delivery, $44.4 billion to $97.3 billion.
• Failure of care coordination, $29.6 billion to $38.2 billion.
• Overtreatment or low-value care, $12.8 billion to $28.6 billion.

These estimates by Shrank et al. do not include the costs of administrative complexity. However, according to Sahni et al . in JAMA 2021, administrative simplification could generate ~$250 billion annually.

Since there is no shortage of money, ideas, policy recommendations, and organizations committed to advancing the agenda to support primary care access:

• Why has the United States been unsuccessful in reversing the trend in primary care access?
• Which two recommendations from the NASEM report do you believe would have the greatest positive effect on primary care access?

The Population Health Alliance (PHA) is committed to Quality and Continuity of Care.?Our key priorities are advancing value-based care, improving consumer engagement, and addressing social determinants and health equity. Join us. Find out more on our membership page .

Michael S. Barr, MD, MBA, MACP, FRCP

Sr. Director, Population Health Improvement

Population Health Alliance

The GPT Generation

I asked ChatGPT 4.0 to complete the following analogy:

?"Population health without primary care is like…"

And it responded:

“Population health without primary care is like a garden without a gardener. Just as a gardener plays a crucial role in planting, nurturing, and protecting plants to ensure a thriving garden, primary care is essential for monitoring, maintaining, and improving the health of a population.”

?(When I asked it to be funnier, it responded with, “Population health without primary care is like a symphony without a conductor - you might have all the instruments, but good luck making sense of the tuba's solo health plan and the violins insisting on playing nothing but yoga stretches!”)