The Future of Primary Care – Some Expert Opinions
by Dr. Jon Hart
At the Reimagining Primary Care Forum this spring, Joel Brill, MD moderated a panel discussion on how to build the future of primary care. Dr. Brill asked the panel what one thing they would change in primary care if they had a magic wand. The answers were as follows:
Aaron Hoffman, DO, MPH – “Healthcare coverage is not the answer; healthcare access is. I would improve access to care.”
Gary Price, MD – “Change federal policy on investments used to address social drivers of health (SDOH) as medical expense and deliver care that creates wellness and leads to better coordination of community resources with the medical system.”
Erika Pabo, MD, MBA – “Give sufficient, meaningful time to patients and providers to build relationships in primary care, hopefully through leveraging technology.”
David Duong, MD, MPH – “Decrease the amount of time in the EHR.” (Also, hopeful about tech.)
Priscilla Wang, MD, MPH – “We have long known that 80% of health and outcomes are influenced by SDOH, but 100% of the medical industrial complex is dedicated to a biomedical model of care. We need to create a truly integrated health ecosystem, with communities of care that can address SDOH in addition to medical issues, including closed-loop referral systems.”
Dr. Brill was surprised that not one of the panelists mentioned payment in their Magic Wand answers. Those of us familiar with primary care and with the need to create value in healthcare were not.
We have recognized for a long time that success in healthcare delivery will rely on both access to primary care and the alignment of incentives to appropriate goals, regardless of who’s paying what on a fee schedule.
If the goals for our healthcare are billable charges and paid claims, then, yes, fee schedules and maximizing payments for billable encounters are important. However, if the goals are optimized health and well-being with improved outcomes, the financial incentivization needs to focus on ways to improve those outcomes.
All the panelists’ answers above touch on that alignment.
The health and well-being of a population cannot be positively impacted without access.
Failing to address the social drivers that negatively impact our patients will simply lead to continued poor outcomes.
Relationship building and maintenance is imperative to a trusting relationship, which is the bedrock of effective healthcare.
We need to leverage tech in ways to help scale and broaden the reach through the humanness of medicine, not continue to promote the dehumanization through unwanted “communication,” endless tasks, and extra clicks.
Each of these speaks to the need to have a goal of improved outcomes – that is, improved health and well-being – and line up the financial incentives to pay for the processes and technology needed to best accomplish that.
Later in the panel discussion, when the fee schedule was brought up by Dr. Brill and panelists were asked how it impacts the care of patients, Drs. Price and Wang shared some insightful comments. Dr. Price noted that our system, like most in business, works on financial incentives. In his opinion, we could do a better job improving care and outcomes if we financially incentivized a whole patient approach.
Dr. Wang cut deeper to the root: “The fundamental issue is that we haven’t defined what it is that we really care about. We need to set the priorities first, then figure out a payment model. Medicine can’t solve all the problems impacting our patients, so we need to partner with others on this.”
What do we really care about? That’s the crux, isn’t it?
The US healthcare system is currently delivering the results it’s designed to create – high claims dollars paid for billable encounters, regardless of outcome. In fact, a cynical observer could argue that the current system spurns good outcomes in favor of needing more billable encounters to fix the problems created by its poor delivery of care.
What’s the solution? Probably, more accurate wording would be what are the possible solutions, plural? There will likely need to be more than one way to solve the problem of climbing US healthcare spend, declining interest in primary care, and the continued downward spiral of US health outcomes as a country.
What does seem to be agreed on is that the goal of healthcare delivery in the US needs to change from profits to outcomes. To align with this, the financial incentives need to encourage and support care aimed at improving health and well-being, and thereby improving outcomes. In doing so, we need to vocally acknowledge the impact of non-medical forces adding risk in our patients’ lives and work to mitigate those risks.
One way to focus on results and tie compensation to them is through value-based care, or more precisely, vale-based contracting (VBC), as was the focus of most of the Reimagining Primary Care Forum. The expert panel in the discussion had some differing views on VBC.
Dr. Hoffman remarked, “If VBC was working, we wouldn’t be having this conversation. Burnout wouldn’t be a crisis. Medical students would want to do primary care. Patients would have access to care. There are good things that come from VBC, but it’s not fundamentally solving the crisis in primary care.”
This was countered by Dr. Parbo, “VBC is a critical part of a solution. The problem is that there have been so many poor attempts at VBC that we start to want to throw up our hands.”
She went on to say that within full risk models, one can do some truly transformative things, despite the profit plays that have been out there distracting us. “I have yet to see a fee-for-service model that can deliver the kind of outcomes, capacity, or care delivery that our patients deserved. It is necessary, but insufficient.”
As I’ve mentioned several times on the BoPC platform, value-based contracting is not the only way to create value in healthcare delivery. When done right, though, it can be a powerful vehicle for improved quality, lower cost, and enhanced experience. As Dr. Parbo notes, though, too many times in recent years we’ve seen poor attempts at VBC or faux-VBC, and that’s both discouraged and jaded us.
Look for ways to use VBC to truly create value, not just as a decoration to put on top of your fee-for-service chassis.
A broader appeal was made by Dr. Wang, focusing on the work to be done rather than the payment model. “Get to know your neighbors and know your health neighborhood. PCPs always feel so alone, and we need to understand all the help that’s out there.”
This resonated with many of the speakers throughout the day of the forum who said primary care has changed, and we can’t continue to hold to the notion that only physicians can keep people healthy. It takes a team, and one that lives outside the walls of traditional medicine. (Be sure to look for the upcoming BoPC article on Team-based Care inspired by this same forum.)
Technology, of course, needs to play a role in scaling out primary care services, making them more efficient and more effective. Dr. Parbo offered an admonition about technology’s role as we find ways to increase access and capacity for primary care.
After advising all in attendance to get familiar with tech like artificial intelligence (AI), she warned, “Be thoughtful about how the increased capacity created from the use of tech like AI is used and how your organization reinvests that capacity. If we just take that capacity and we make the hamster wheel go faster, we’re not going to solve anyone’s problems. We’re still going to have a primary care shortage. We’re still going to have docs who feel their jobs are not doable. We have to be very thoughtful in how we reinvest that capacity.”
The future of primary care doesn’t depend on a fee schedule for physician services rendered. Improving the health of our nation while bringing medical costs under control relies on two factors: 1) building and scaling of primary care and all the team players needed to positively impact the health of people, and 2) a conscious and intentional decision to prioritize health outcomes as our goal, aligning financial incentive with that goal.
Execution on these two factors will need to focus on
effective and humane leveraging of technology to build and scale healthcare delivery systems that nurture relationships
identification of the medical and non-medical influences on a person’s and a population’s health and well-being
construction and maintenance of teams and processes beyond the walls of the physician’s office to address these identified issues
and financially incentivizing all these actions
With these steps, we can positively influence (and reimagine, if you will) both primary care healthcare delivery in the US, as well as the health, well-being, and health trajectories of our patients and their families.
Participants in the panel discussion referred to from the Reimagining Primary Care Forum 2024 included:
Aaron Hoffman, DO, MPH. Chief Clinical Innovation Engineer, Atrius Health
Erika Pabo, MD, MBA. Chief Transformation Officer & Central Operations, Humana
Joel V. Brill, MD FACP. Executive Medical Director, Hello Heart
Gary Price, MD. President, The Physician’s Foundation
David Duong, MD, MPH. Director of the Program in Global Primary Care and Social Change, Harvard Medical School
Priscilla Wang, MD, MPH. Associate Medical Director for Primary Care Health Equity, Mass General Brigham
