The U.S. Dept. of Health and Human Services (DHHS) initiative to Strengthen Primary Health Care, launched in September 2021, aims to establish a federal foundation that supports advancement toward a goal state of the practice of primary health care.
In its goal state, the practice of primary health care:
- Supports health and wellness through sustained partnerships with patients, families/caregivers, and their communities;
- Equitably provides first contact access to all, as well as whole person, comprehensive care over time, using interprofessional teams; and
- Coordinates and integrates care across systems, including other health care providers, public health, and community-based health promotion and social service organizations.
Foundational to strengthening primary health care is building trust between care providers and care recipients. Establishing and strengthening trust depends on the depth and duration of the interpersonal relationships created. Therapeutic relationships are built on a thorough and joint understanding of the factors in a patient’s life circumstances that contribute to health issues and an agreement on potential interventions and solutions to address these issues.
This approach will only truly be successful when enabled via multiple approaches in today’s healthcare culture. According to the World Organization of Family Doctors, the aim of effective family medicine, and in turn effective primary care, “is to promote personal, comprehensive and continuing care for the individual in the context of the family and the community.”
Successful and equitable primary healthcare access across cultural, ethnic and sociodemographic features requires a robust primary healthcare workforce. According to 2020 data, an estimated 22% of clinicians in the U.S. choose a career in primary care.
The American Medical Association also found that “graduates of osteopathic schools disproportionately help to fill the gap in primary care.” According to the Canadian Medical Association 52% of physicians practice primary care. In Europe, many countries have much greater than 50% generalist physicians per 100,000 population, in some cases exceeding 70%, compared with 42% in the U.S. Our Canadian neighbors and our Western European allies surpass us in most if not all measures of health care quality and lifespan.
They have actively practiced what we have continued to downplay — that a variety of social, economic and political factors are behind America’s relatively low life expectancy at birth. These include the lack of universal health care, a poorly functioning public health system, insufficient federal drug oversight and unhealthy lifestyles that contribute to chronic illnesses. Promoting a robust primary care workforce absolutely requires widespread mentoring and role modeling by practicing primary care physicians.
Nearly 75% of primary care physicians — newly graduated and those already established — are now practicing in a hospital/healthcare system employment arrangement. The days of the independent primary care clinician are rapidly disappearing, primarily due to overwhelming administrative and insurance system burdens.
They are subject to wRVU quotas (The acronym wRVU refers to work relative value units. Here’s how it works: For every patient examination or procedure performed, a clinician receives a certain amount of work RVUs. Those wRVUs are then multiplied by a conversion factor, which is a specific dollar amount. That largely determines what a clinician earns. Numerous Quality Metric income incentives (percentage completion goals in areas of cancer screening, vaccinations, well visits and chronic disease management like diabetes demand attention). They are important, but when pushed too hard by the health systems that derive revenue from “hitting the predetermined benchmarks,” compete with essential role modeling/mentoring of medical students the skills needed (i.e. active listening) to build deep and enduring relationships with patients.
HHS needs to formalize an “educational” RVU system and payment mechanisms that, among other topics, encourage and support undergraduate medical student primary care mentoring/role modeling.
Newly graduated medical residents choosing to practice primary care have increasingly “siloed” their practices. In much of the country, gone are the broad scope practices where primary care clinicians deliver ambulatory, hospital inpatient and home visit care.
“SNF’ists, Intensivists and hospitalists” are now pervasive. This dramatically limits the clinician’s ability to truly “know” their patient. It has been proposed and often validated that 40-50% of individual patient behaviors (diet, level of exercise, tobacco use etc.) directly contribute to health outcomes and 20% are attributable to the individual’s social and physical environment.
The Social Determinants of Health (SDoH) are the conditions in the environments where people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning and quality-of-life outcomes and risks. SDoH data networks like “Findhelp” and organizations like “Unite Us” are important, provide crucial links to SDoH local resources and need to be shared across the universe of healthcare providers and allied health professionals at all levels.
But we can do still more. We now have over 80 ICD-10 (International Classification of Diseases) diagnosis codes that address SDoH. Documenting these codes directly supports broadened recognition of a patient’s social/behavioral/environmental health interaction and active recognition of the time needed to address this relationship justifiably enhances primary health care billing in our fee-for-service medical system — but we can do more. The goal must be to screen for SDoH needs, connect individuals to needed services, close the communication loop and track clinical and medical service utilization outcomes.
Community health workers are lay members of the community who work with the local health care system in both urban and rural environments. They usually share ethnicity, language, culture, socioeconomic status and life experiences with the community members they serve. Community health workers can also partner with community members to target specific social determinants. These workers can support other community members as they arrange town hall meetings to educate peers or work with policymakers to implement the changes needed to improve health and wellbeing.
HHS should formally recognize and support the growth of a community health worker workforce to embrace the value of addressing social determinants of health as essential to health care delivery and health care outcomes.
Health Information Exchange (HIE) is critical to providing coordinated care to our patients.
Additionally, as primary care providers of all “stripes” — physicians, APRNs, PAs, LCSWs, administrative staff etc. — we must help our patients navigate the extremely complex web of healthcare “systems” that comprise the American Health Care culture. This requires team-based care.
Accountable Care Organizations within health systems were designed to provide this integrated service. It is unclear how successfully team-based care has been achieved, this varies widely by healthcare organization. Equally variable is HIE. This has been very unsuccessful in states where many health systems and electronic health records exist, NONE of whom truly share data. This renders it nearly impossible to coordinate clinical care and deliver “high-value” care to our patients-duplicative care and presumed care gaps are widespread. This is unacceptable.
Unfortunately, a volume-driven and revenue-prioritized healthcare system competes with initiatives to alter the paradigm. Population health data now allows for outreach to patients on a scale not previously imagined or achieved. We can now apply the National Committee on Quality Assurance (an independent nonprofit organization in the USA to improve healthcare quality) health quality measures to a larger percentage of the population whose care is attributable to our clinical practices.
The goal, however, should not be driven by potential increases in earned compensation when target metrics are achieved, but rather the enhancement of the health of our attributable patient populations. And we MUST NOT degrade the individual patient-clinician relationship by “over-focusing” on population metrics.
HHS has here the biggest challenge: to alter the landscape of healthcare financing, to prioritize care coordination and cost effective use of resources that do NOT emphasize the shareholder value and the “return on investment” (ROI).
Finally, technological innovation cannot be ignored. Web-enabled devices such as smart watches, web-enabled blood pressure cuffs and glucometers that transmit data to healthcare providers, continuous glucose monitors that give patients more ownership and control over their disease management and patient portal participation need to be encouraged and supported.
Audio and audio-video remote clinical encounters facilitate sustained communication between patient and provider, as do “e-consults” (a mechanism that enables primary care providers to obtain specialists’ inputs into a patient’s care and treatment without the need for a face-face visit. These “remote” encounters allow for up-to-date clinical care in rural and remote areas. Deployment of all these clinical support systems strengthen the web of clinical communication and relationships critical to elevating the health of the public at large.
HHS must support a robust web-based healthcare system that values remote healthcare technology every bit as much as face-face encounters.
The time is NOW and long overdue to step up to the plate, put our “boots on the ground” and make these and other essential changes to support the health of our population.
Howard A. Selinger MD is Chair of the Dept. of Family Medicine at the Frank H. Netter MD School of Medicine at Quinnipiac University. He is also on the faculty of the ECHN Family Medicine Residency in Manchester.