October 25, 2024
How Do We Fix Primary Care?
By Jake Berman, MD, MPH
Consider the plight of today's primary care physicians and practitioners.
First, clinical guidelines for screening, preventive health, and chronic disease management continue to grow in number and nuance, yet the time and resources needed to address them remain stubbornly fixed and insufficient. By some estimates, PCPs would need 26.7 hours per day to render guideline-concordant care for a typical panel of 2,500 adult patients 1. It has been observed (with biting wit) that progress could be made if "general practitioners could reduce the frequency of bathroom breaks to every other day and skip time with older children who don't like them much anyway." For PCPs, the supply-demand mismatch is real, painful, and unsustainable, a common source of stress, burnout, and moral injury.
Second, in the face of these impossible demands, the PCP often remains a lone warrior, expected to address an enormous range and volume of tasks, many of which do not require the PCP's clinical expertise and many of which would be better addressed by the expertise of other health care professionals or community partners. Team-based care to support primary care patients is far from a novel concept, yet its implementation has often come in fits and starts, and many practices struggle to achieve sustainable, integrated team-based care models.
Third, such challenges in establishing and scaling effective team-based care arise in no small part because spending on primary care remains woefully inadequate. According to current estimates, in Washington state, only 4.4-5.6% of health care dollars are spent on primary care, far short of the state's goal of 12%. This yawning gap is acutely and chronically palpable for the PCP.
Finally, the pain points of primary care practice are driven not only by investing too little in primary care but also by the way in which we generally pay for primary care. Despite some forays into and some successes with value-based models, billable encounters with PCPs, which do not incentive quality and constrain the variety of ways in which primary might be rendered, largely remain the coin of the realm for many primary care practices. As the National Academies of Science, Engineering, and Medicine recommended in its landmark 2021 report Implementing High-Quality Primary Care, "Pay for primary care teams to care for people, not doctors to deliver services." Paying for teams to take care of people not only better aligns the incentives for high-value, patient-centered care but also opens the way for innovative, multimodal primary care models that can more flexibly meet diverse patient needs. The tension between primary care's business model and its clinical paradigm creates dissonance for PCPs, care teams, and patients alike. The Work Relative Value Unit simply does not describe primary care's value or lend itself to meaningfully assessing PCP performance.
Fortunately, there is hope, not only on the horizon but in the waters in which we currently swim.
In June 2023, the Centers for Medicare and Medicaid Innovation announced a new primary care model called Making Care Primary. MCP seeks to support primary care through a combination of upfront capacity-building payments and a gradual transition from fee-for-service to prospective population-based payments for primary care services, with a host of resources and incentives to advance quality, equity, efficiency, and patient experience. Washington state was selected as one of eight states to participate in MCP, in no small part because the Washington State Health Care Authority was looking to integrate the program with its Primary Care Transformation Initiative, which includes an ongoing effort to advance a multi-payer primary care model increasingly built on value-based payments. In Washington, 21 clinical practices have enrolled and 11 payers have signed a letter of intent to align with the model.
MCP is not a panacea. Nor is it the only way forward. Yet, the model is engineered to foster—and invest in—team-based care, care integration, and, ultimately, an approach that pays for the value of primary care relationships rather than billable encounters. For PCPs, this could mean a reimagined clinical workday, with investments and a payment model that enable more time and flexibility for patient care through whichever channel works best—a brick and mortar visit, a digital visit, the electronic inbox, remote patient monitoring, the community—and support for a care team that is better-suited to addressing the scale and variety of patient needs. With an effective care team, the estimate of PCP time needed to provide guideline-concordant care dropped from 26.7 hours per day to 9.3 hours per day-still too much, but a marked improvement 2.
How else could a program like MCP truly impact the everyday life and work of PCPs? Among other things, the model seeks to support better integration of care between PCPs and specialists, including through a new e-consult code that pays specifically for the work the PCP does to place and follow up on a virtual consult. MCP also supports investment in building desperately needed behavioral health capacity, such that PCPs could have better access for their patients to counselors, social workers, and psychiatrists. Significantly, MCP also seeks to better integrate medical services with community resources by incentivizing the collection of data on health-related social needs and providing resources that can be invested in roles like community health workers, who may be best positioned to support and engage patients in their everyday lives. Have a patient whose diabetes is nearly impossible to manage given food insecurity? The MCP care team could include a community health worker able to assist the patient in troubleshooting root causes and pursuing nutritional resources. At its core, the model looks to enhance the primary care medical home while situating this medical home in a more cohesive medical neighborhood, empowering PCPs with more and better-integrated resources to support their patients.
MCP will be what we make of it, and the types of organizational, cultural, and practice change required for success can be complex. But with the resources provided by the program and with thoughtful execution, PCPs could chart their way out of the current predicament to a future where they are set up successfully to do what so many of us originally signed up for: make care primary.
Jacob Berman, MD, MPH, is the medical director for population health integration at UW Medicine and a clinical associate professor in the department of medicine at the University of Washington. This essay reflects Dr. Berman's own views and not those of UW Medicine.
This article was featured in the November/December 2024 issue of WSMA Reports, WSMA's print magazine.
1. J GenIntern Med 38(1):147–55 DOI: 10.1007/s11606-022-07707
2. J GenIntern Med 38(1):147–55 DOI: 10.1007/s11606-022-07707