Primary care in the U.S. is at a unique inflection point. On one hand, the value of primary care physicians has never been higher. The evidence of that is in the tens of billions of dollars of investment in healthcare – more than $39 billion invested in the sector last year alone, with a notable focus on primary care.
On the other hand, the threats to primary care have never been greater. PCPs face operational burdens on capacity, talent and infrastructure. They see soaring demands on access and availability. They experience additional pressure to deliver better outcomes – all without the necessary resources to support these daunting demands.
Dr. Christopher Crow is cofounder and CEO of Catalyst Health Group, a primary care network that works for physicians and patients. Healthcare IT News sat down with him to discuss what he calls the push to advanced primary care and the role of technology and tech-enabled care teams to achieve it.
Q. What is the state of U.S. primary care today? Is it failing in any places? If so, where, and what needs to be done to fix it?
A. While investment dollars may be flowing into the sector, the overall focus of dollars toward primary care remains mediocre, at best. America spends half of what other developed countries spend on primary care, despite it being the single area of healthcare that has proven to deliver actual cost savings with better population health results.
So, what has happened as a result? People stop seeking out primary care in the times when preventive, proactive care could make the most difference. U.S. adults are the least likely of those in other developed countries to have a regular physician, place of care or longstanding relationship with a primary care provider.
What else has happened? PCPs are simply burning out. Many active care providers have left or are considering leaving the profession, taking new positions in the medical field. Others are choosing not to enter it in the first place.
Inadequate pay and support have left physicians with few choices, and because of systemic challenges like these we face a dangerous shortage of physicians. According to the Department of Health and Human Services, the U.S. needs 16,000 more PCPs to meet the demand for consistent care.
The effects of this are far-reaching, impacting health outcomes and costs. A March 2022 study led by the American Medical Association found $979 million in excess U.S. health spending annually comes from primary care physician turnover, with more than a quarter of that – $260 million – attributable to burnout. It couldn’t be clearer: Our PCPs need more help.
But identifying the problems and putting proven and scalable solutions into practice are two distinctly different tasks. Fortunately, there are answers, and those answers extend beyond the introduction of more technology. While technology innovation is a key component, creating more access, capacity and sustainable value for primary care requires us to step back and reimagine primary care itself.
Adopting an extended team-based approach to care is step one – enabling PCPs to be leaders of integrated teams that include their own office staff, plus additional virtual team members: care managers and care coordinators, pharmacists, social workers, behavioral health specialists, and others.
Step two requires the implementation of new payment models that align payment directly with patient health and allow physicians to do the jobs they’ve always envisioned. The results will be transformative, and when we get there, all communities will be healthier, costs will be lower and PCPs can be affirmed in their role as champions of health for their patients.
Q. Please explain the difference between “direct primary care” and “advanced primary care.”
A. It’s easy to see how the terms might introduce some confusion. Direct primary care is exactly how it sounds: Primary care that patients access directly, without having to go through an insurance company or government payer. Patients pay their physicians directly on a fee-for-service basis or through other models like monthly memberships.
There are more than 16,000 direct primary care practices in the U.S., and the leading benefits associated with this model include quicker access to appointments, because the PCPs often carry smaller patient panels and lower costs compared with other care-on-demand settings like urgent care or the emergency room.
Advanced primary care can be similarly defined by how it sounds: primary care that goes beyond a traditional or basic delivery model. In a traditional primary care model, you see a PCP, or perhaps a nurse practitioner or physician assistant. This interaction typically happens in-office, though increasingly, because of COVID, it occurs virtually as well. Any questions or follow-up would go through the PCP or the practice’s staff.
Advanced primary care takes that further, extending the care team to include the capabilities I mentioned earlier: care managers and coordinators, pharmacists, social workers, and others. These additional resources support patients along their care journeys and in between the times that patients are in front of their doctors.
They expand the capacity of PCPs by answering patient questions, addressing common obstacles like medication management or social determinants of health, and ensuring that patient-specific care plans are carried out. Throughout the process, they are making sure that the PCP is kept in the loop, which again reinforces the notion of the PCP as the leader in each patient’s care journey.
If it sounds like this model could work to improve experience and outcomes, it absolutely does. The one giant barrier to resolve is aligning incentives and payment.
Traditional primary care is stifled and strangled by the reactive, volume-based model of fee-for-service. Unlocking the full value of primary care requires a value-based, prospective payment model that incentivizes PCPs and their extended care teams to deliver preventive care and support patients throughout the care journey.
Q. What role does health IT play in enabling an advanced primary care model for physicians?
A. Primary care under traditional delivery models isn’t just unsustainable – it’s borderline impossible. Studies have estimated that it would take nearly 22 hours per day for a PCP to provide all recommended acute, chronic and preventive care for a traditional patient panel of 2,500 patients, which is close to the average panel size in the U.S.
PCPs lack access to the data, technologies and support needed to care effectively for patients, maximize their impact on patient health, foster meaningful relationships and ultimately demonstrate the immense value that primary care can have on patients’ lives.
This combination of factors forces physicians to overcompensate and overextend themselves to the point of burnout, and leaves many people feeling like primary care only exists as a transactional experience.
The shift from this current reality to one where advanced primary care is the norm certainly requires the right digital solutions that can connect, optimize and support everything from practice workflow to patient engagement and chronic condition management.
However, the key to enabling advanced primary care isn’t just the technology, it’s also the teams and how they’re able to use such technology in integrated ways to deliver a cohesive, personalized care experience in every moment that matters.
When this occurs – when technology-enabled care teams can relieve clinical and operational burden for physicians – PCPs can care for more people, prioritize a relational model of care delivery and do so in sustainable, scalable ways that can transform the care experience for millions in our country.
For example, according to the CDC, six in ten Americans deal with at least one chronic condition, and many also face logistical challenges in accessing care. Lack of transportation or family support makes it difficult to schedule or get to appointments, get prescriptions filled, or properly follow treatment plans.
Such factors often are unknown to physicians but lead to declining health for their patients. Having a fully informed, connected care team gives patients more support, more frequent touch points and builds more engaging, informed relationships to help mitigate problems they face along their care journeys.
Q. How can providers better use team-based care and health IT to deliver a better healthcare experience for patients?
A. We can all relate to the pains of traditional primary care – all the time spent waiting and wondering, just for the chance to spend a few precious minutes with the PCP to get answers and help. Team-based and technology-enabled care changes that.
When team-based care and digital solutions are used more effectively, primary care will no longer be defined as the time patients spend with their PCP in the exam room, or even on a telehealth call. It will no longer be the transactional encounter that prioritizes only convenience and speed.
Instead, it will become a relational experience, where patients have more expertise available to address their spectrum of needs – from successfully transitioning from one care setting to another, to navigating different specialists, to disease state-specific support, to medication-related concerns.
But to see these benefits, providers must engage and trust the model. For patients to view care team members as extensions of their PCP’s staff, the PCPs themselves must treat the care team as such – including how the PCP introduces the concept of the extended care team to patients. We’ve seen team-based care transform the patient experience when PCPs take time to create clear connections for their patients.
Referring to the virtual care team as “my care team” and explaining that this is “a team of nurses, pharmacists and other specialized experts who help me care for my patients” generates understanding and peace of mind for patients. More crucially, it dramatically increases the rate of initial engagement and sets the stage for longer-term success for patients, and for physicians.
Q. What barriers must providers overcome to achieve advanced primary care and/or primary care for all?
A. The largest barrier is the current fee-for-service system. Fee-for-service inherently is flawed, but also ubiquitously deployed. So, what have we seen as a result historically? Reactive care, prioritizing volume over value, a series of disjointed steps rather than a singular, connected experience.
The entire system has been set up this way, and even though we know this ship is sinking, it’s too large to turn around as quickly as we’d like. Inertia has been – and will continue to be – a huge impediment to transformation.
Again, value-based, prospective-payment models have been proven to deliver the outcomes wanted by patients, providers and payers. They support proactive healthcare by financially incentivizing physicians to keep patients healthy.
The good news is we’ve seen this model work already with Medicare Advantage programs, and momentum seems to be shifting toward exploration of more advanced primary care models. The question will be whether enough decision-makers and market influencers can accelerate the pace of change while staying true to the vision of what primary care was always meant to be.
A second barrier is, perhaps surprisingly, physician adoption. You would think most if not all physicians would be on board with a shift to a model that would prospectively pay them to take care of patients and help them live healthy lives.
However, at a recent meeting of Catalyst Health Network members attended by nearly 400 providers, one in six provider attendees expressed they still have skepticism about prospective payment as a concept.
Part of this hesitation might be because everyone has become so accustomed to the current system, something of a similar nature to Stockholm Syndrome. Or maybe it is that physicians feel overwhelmed by how daunting a shift to prospective payment could be.
This kind of switch is not a light move, as it requires a series of steps, investment of resources, the ability to stand up and lean on technologies and teams that provide the necessary support for patients. And at the same time physicians and practices must often keep a foot in both camps – practicing medicine in the traditional fee-for-service model while transitioning to prospective payment and waiting for the rest of the world to catch up.
It’s less of a glide path and more like building a bridge to cross the chasm. It’s nearly impossible to do alone, which is why physicians are turning to like-minded partners for help in guiding these steps and proactively delivering the support services needed when prospective payment does become the new normal.
And it is all the more reason that we need to continue to push for this – to stoke the fires of belief in a better, more pragmatic system of primary care, to help all stakeholders understand that healthcare can truly and finally prioritize the one thing that’s been conspicuously missing in our traditional model: health.