A strategic blueprint for fixing primary care
Nothing in the U.S. health care system will be or should be the same after a two-year global pandemic. Our primary care system has recovered in some ways from the sudden financial shock and the loss of patients, but a closer look suggests it is still the same under-performing, under-funded, and under-cared-for prepandemic system. That needs to change over the next five years. Here is a blueprint detailing how.
Goal 1 Transform the Way Health Care Treats the Primary Care Workforce
We knew that doctors, nurses and pretty much all other primary care workers were overworked and burned out prior to the pandemic. The pandemic made it worse. Things like burnout and job dissatisfaction do not get better on their own. Health care employers will have to radically alter how they view and treat their workforce. In business, successful companies apply a concept called “talent management,” which involves a sustained and holistic approach to recruiting, motivating and retaining workers. It forces organizations to become desirable places to work. It also involves employers seeing their employees as individuals with unique needs, wants and situations. To achieve this goal, primary care employers must move beyond compensation as the chief human resource focus for physicians, nurse practitioners, physician assistants and nurses, and work on meeting the full range of their workplace needs. Employers must redesign health care jobs and work settings with this in mind.
Goal 2 Allow Patient Choice to Drive the Primary Care Marketplace More, Not Less
Patient choice was never really taken seriously in primary care before the pandemic. But it must be taken seriously now. For example, the inconveniences that still exist in trying to schedule, get to and follow up on primary care provider visits are unacceptable. Patients want choices for when and how they access their primary care. They want low-cost options, virtual and in-person options, easy access and convenience, and real-time communication. Primary care providers and their offices need to embrace digital health tools and a new mindset that regards patients as their customers. Virtual primary care delivery, which has fallen off dramatically since the height of the pandemic, should become more mainstream than it is now, especially for certain diagnoses and for patients with already established relationships with primary care providers. Electronic patient care portals must be more interactive, operate in real time, and be designed with input from the user, the patient, on how they wish to use them. Most patient portals remain asynchronous, lack interoperability, and are limited in their functionality from the consumer side.
Patients should have 24/7 access to their primary care provider’s office, not just nine-to-five access. That’s a mindset change as much as anything else, and primary care doctors know it. Yes, payment will need to account for some of this extra access and time by providers (see below), but payment cannot be used anymore as an excuse. Physician-centric primary care as we know it will continue to decline unless patients have more choice in how they wish it to be organized and delivered to them. Primary care physicians will continue to lose relevance with their customers if they do not deliver on the choice imperative.
Goal 3 Stop Big Delivery Systems From Making Primary Care a “Loss Leader”
Big delivery systems that continue to spread weedlike throughout the U.S. treat primary care as something beneath them––a loss leader important mainly for stopping patient “leakage” to outside specialists and other delivery systems with whom they compete. These systems, most with hospitals and powerful specialty groups at their core, must be forced to take primary care delivery more seriously in letting their primary care providers, and not their specialists, manage more of the chronic disease and preventive needs of their patients. They need to make their brand of primary care less transactional and corporate-like, and more relational and human. They need to be incentivized or forced to focus on keeping their patients healthier. In a best-case scenario, there should be more free-standing primary care offices that are not so closely aligned economically with these large hospital-based systems. This falls on individual primary care doctors to make happen and on government and venture capital to help seed fund it. Collaboration with tech companies that can provide digital health tools for these stand-alone practices at reduced cost is also a good idea.
Goal 4 Give Payment Control to the Primary Care Provider and Patient
We have been saying for decades how we need to invest more in primary care and keeping people healthy. But it really has not happened. Call it value-based reimbursement, bundled payment, global capitation, whatever—the words no longer matter. They are the toothless, feel-good vocabulary of an army of policy makers and industry executives who have been unable to see the follies of an approach to fixing primary care payment that depends on providers creating reams of documentation; moving through authoritarian quality checklists for every type of visit and patient; reading and reacting to a mass of analytics about how they should take care of their patients; and being chastised constantly for falling short per some half-evidence-based clinical guideline.
That’s not a good payment system. That’s a Pavlovian one that turns primary care providers into dissatisfied and burned-out lab rats. Move to payment systems that return on-the-ground decision- making and control to the individual provider, payment systems that reflect trust in how they do their jobs. Give providers the freedom to interact with patients how they see fit, and in the process get rid of much of the inane documentation requirements that add no value for either patient or provider. Not everyone needs a detailed checklist to help assure they receive appropriate care. Hold primary care providers accountable but in more global ways that do not require them to justify their decisions for every patient. Push risk onto them but also give them the appropriate amount of funds up front to manage this risk at a population level; don’t dole out the dollars in piecemeal fashion.
Goal 5 Amass an Army of Primary Care Providers at Different Skill Levels
We know there won’t be enough primary care physicians to meet the needs of our system moving forward. But we also face shortages of nurses and medical assistants, both of whom increasingly shoulder more administrative and basic care duties in primary care. Medical schools alone cannot be relied upon to turn out more primary care physicians. They have no incentive to do so.
More initiatives of the kind that Kaiser Permanente has developed, in which they invest in developing primary care physicians, should be encouraged. There needs to be much more loan forgiveness for those wishing to pursue primary care careers. Establishing a plethora of health training programs in community colleges for medical assistants, who now do most of the primary care prep work, makes sense, and reaching into high schools to attract select individuals to such careers can be part of that initiative. Make the employers who need these types of positions invest in the training programs in return for having graduates work locally in their organizations for a period of time.
These are just the big picture strategies, and there is much more to do. But until the overarching blueprint gets articulated and adopted, the tactical details will remain devalued.
Timothy Hoff, Ph.D., is a professor of management, healthcare systems, and health policy at Northeastern University in Boston, Massachusetts, and author of the new book, “Searching for the Family Doctor: Primary Care on the Brink” (Johns Hopkins University Press).