What Are We Prepared to Do in the United States to Save Primary Care?

Kim BellardEverybody loves primary care. Everyone notes how crucial it is to our health. And, increasingly, it seems like everyone laments how it is in decline, especially in the United States.

To paraphrase Sean Connery in The Untouchables, what are we prepared to do about it?

Two recent studies bring focus on the situation: The Commonwealth Fund's International Health Policy Survey of Primary Care Physicians, and a study from Harvard Medical School researchers Characteristics of Americans With Primary Care and Changes Over Time, 2002-2015.

Some highlights:

Commonwealth Fund

• The U.S. trailed all 10 other nations in primary care physicians who made home visits or provided after-hours arrangements;
• The U.S. was at or near the bottom in terms of receiving information on their patients from specialists or from emergency room visits;
• The U.S. was near the bottom in terms of coordinating patients with social services or community resources;
• Although the U.S. scores moderately well in Health IT options, it is among several nations where interoperability remains a challenge.

Their conclusion:

Improved technology alone will not suffice. Common ingredients of initiatives across countries include a strong commitment by government and other payers to primary care, the development of innovative care models, and active cooperation among professionals from the health care and social services sectors.

Harvard Medical School

• Since 2002, the percent of adult Americans with an established source of primary care has dropped from 77% to 75%;
• The decreases happened in all age brackets up to those in their 60's;
• For adults in their 30's, only 64% have such a source;
• "Those who are male, Latino, Black, Asian, uninsured, and living in the South are much less likely to have primary care."

Lead author David Levine, MD, warned:

Primary care is the thread that runs through the fabric of all health care, and this study demonstrates we are potentially slowly unweaving that fabric. America is already behind the curve when it comes to primary care; this shows we are moving in the wrong direction.

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We have to keep in mind that, in the U.S., only about a third of physicians are primary care physicians, and medical school students are less likely to choose the field, driven at least in part due to lower salaries. Harvard's Dr. Levine noted: "Everywhere else in the world, 'primary care first' is the health care model."

Not so much here.

There have been many efforts to change the situation, such as the Primary Care Medical Home, or proposals for medical school debt forgiveness for physicians who go into primary care. Others see Direct Primary Care as a route to revitalize the role.

The American Association of Medical Colleges wants the government to fund more primary care residency slots, even though the vast majority of internal medicine residents do not plan to go into internal medicine. We could simply decide to pay primary care physicians more, but other specialties are unlikely to easily give up their income.

Many urge increased emphasis on "physician extenders," such as physician assistants and nurse practitioners. Both fields (PAs and NPs) are booming. In the U.S., there are more of these than there are primary care physicians, although not all of them work in primary care.Others see drugstores as the new home for primary care. Following its acquisition of Aetna, CVS is betting big on its in-store HealthHubs, hoping to have 1,500 "concierge-style in-store centers" by the end of 2021. United HealthCare is teaming up with Walgreens, as is Humana.

Forbes called this strategy "Dr. Drugstore."

So far, though, "retail clinics" have not demonstrated that they save money, substitute for more expensive care, increase access, or improve patients' health. But, in our healthcare system, what does?

The stats are telling us that we're increasingly not establishing primary care relationships. The stats also suggest that our health is on the decline, with half of us expected to be obese within ten years and with declining mortality. More primary care could help, but perhaps not necessarily in the way we are currently thinking about it.

Our health doesn't happen in medical offices, and cannot always be fully discerned in them. Where we live, how we live, even with whom we live and socialize bear greatly on our health. Primary care belongs where we live, not where we visit.

Not even drugstores.

I propose two significant changes to help make primary care relevant in the 21st century:

Virtual Care:

I wrote a longer piece on this earlier in the year. In short, it's a disgrace that we've put so many hurdles on telemedicine, and that it continues to be so underused. It is widely available in health plans, but rarely practiced by physicians nor by patients. Instead, we still mostly go to our doctors offices, to ERs, or perhaps now to drugstores.A televisit should be the first course of action for non-emergencies. We must remove regulatory and reimbursement barriers, and incent patients to take advantage of the speed and convenience of the option.

Moreover, as AI options for diagnoses and advice quickly become more viable, we can use them to triage our needs, help assure continuity with physicians, and eventually reduce the need to talk to a human.

Rethink Primary Care Physician:

We need a new kind of primary care physician.

Other countries have shorter periods of medical education; why don't we do that specifically for primary care physicians? Shouldn't we train primary care physicians more on, say, social determinants of health, social supports, behavior moderation techniques, and less on topics of more importance to other specialties? It's not that primary care physicians need to know less than other specialties as it is that they need to know different things.

We should train a lot of them, and make them easily available. Even for home visits.In China they call them "village doctors" (an improvement over the original "barefoot doctors"). China is also emphasizing AI "doctors." They know they have an access and capacity problem, as do we, but they're addressing it creatively. We ignore their lessons at our own risk.

Some might worry about a status reduction relative to other specialties -- "they're not real doctors..." -- but, if so, that's our fault. They'd be the ones who know our health best, and deal with it the most.

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Neither of these suggestions would be trivial to bring about. Both would face significant opposition from the status quo interests. But those interests are currently strangling primary care, and adversely impacting our health.

Time to do something different in primary care.

Attribution

”What Are We Prepared to Do to Save Primary Care?" was authored by Kim Bellard and first published in his blog, From a Different Perspective.... It is reprinted by Open Health News with permission from the author. The original post can be found here.