Primary care crisis: How to build the practice of the future

July 21, 2020

Primary care was in crisis in the United States — and then COVID-19 happened. How can we create a better model for primary care?

Primary care was in crisis in the United States — and then COVID-19 happened. In part two of our two part interview, Rebecca Etz, PhD, an associate professor of family medicine and population health at Virginia Commonwealth University and co-director of the Larry A. Green Center, discusses physician burnout and how to create a better primary care system for the future.

Watch Part 1 here.

The following transcript has been edited for length and clarity.

Medical Economics: How is the pandemic going to affect levels of physician burnout?

Etz: I'm sorry to say they're greatly increasing. On our survey that we did two weeks ago, we had 60% of clinicians report that burnout was at an all-time high for them and that financial strain was at an all-time high for them.

It's important to consider that many of the people practicing in medicine right now are an older generation. So when they say it's an all-time high, they're drawing on decades. that's saying something because they're including the great recession in there. There is tremendous burnout with primary care. And that's largely because each year we continue to be asked to do more and more, with less and less when the pandemic started. Primary Care was the frontline primary care kept patients out of hospitals. We had patients self-isolate at home and followed up with them on the phone. We had patients who returned from the hospital and needed to be monitored because we didn't understand why so many people were released as healthy and then getting sick again. We had a lot of patients who were worried about whether or not they had COVID-19 and needed to talk to somebody not to mention In the usual occurrence of injuries, accidents, illness, all sorts of things. What we found is that practices felt such a dedication to their patients. They continued to do those things despite the fact that they were now not getting an income. That wouldn’t actually be so bad if they felt valued by the healthcare system. They do not feel valued by the healthcare system.

In fact, our last survey, the results of which we will be posting today show that while practices feel valued by a majority of their patients, they feel least valued by the federal government, and little valued by both hospital systems, health systems and insurers. So burnout is extraordinarily high. And we have open text comments to our surveys. We regularly hear from hundreds of clinicians that they show severe signs of depression. Some share suicidal thoughts, Many talks about sitting in their car and crying before going into work or being nauseated at the idea of having to face another day where the pressures are extreme, the need is great, and the support is next to nil. It's a very difficult environment. We are currently working with the American Psychological Association to try to figure out how to offer more resources to those clinicians that write in on our survey in such distress. I have not seen this level of burnout in at least a couple decades.

Medical Economics: Obviously, burnout is a pervasive issue. And I think it's probably linked to all the systemic issues that we've been talking about in regards to primary care and health care in this country. What do we do about this?

Etz: I'm glad you asked that. The first thing we have to decide is that we are no longer willing to accept the unacceptable. We have to decide that every person has a right to their dignity. Every person has a right to health, and it has a right to being respected and having their healthcare needs met. That's no small thing. I don't say that as lip service. I mean that for real. We have to as a country stop accepting the unacceptable.

The next thing that we have to do is we need to dramatically change how healthcare is measured, how it is funded, and how it is held accountable. We need to separate payment from documentation. And what I mean by that is when you go in to see a primary care doctor, we all know that they complain about not having enough time with their patients. We all know that patients complain about not having enough time with their doctors.

We've actually had research in the past that suggests 20 minutes is ample time and 15 minutes is a good amount of time for a visit. The problem isn't the time itself. The problem is the intrusion of a third party into that visit. So if you're my doctor, and I'm your patient, when you and I enter a room, it's not just about us, and it should be that should be sacred. It should be the time that I get to be my most vulnerable, and you are worthy of my trust. And together we work on the things that concern me with regard to my health. It's not that first and foremost, it's documenting of things of interest to insurers and policymakers. These are not the things that are the main concern of the people who walked into the room. I'm not saying we don't need to be held accountable, but I am saying that most measures are Based on disease, disease processes and disease outcomes, and as I mentioned before, 80% of primary care happens absent diagnosis. So if we know that and it's a basic, nobody's debating it, we actually know that we know that, then we need to stop the fool's errand of measuring and paying based on that. We also can't pay primary care based on specific diseases. When we know it sees all diseases, it sees all people, it sees everybody from prenatal to when they pass away, we see the full spectrum, we have to understand how to value all parts of that internal medicine, family medicine, pediatrics, all of these fields are critical to the foundation of a generalist discipline that we call primary care.

So the way that we support it and we make it better is we have to have the will stop accepting the unacceptable. And we have to be willing to change fundamentally change our payment systems such that they reflect the work of healthcare. That is how health is won and lost among our population, and not the business model that we think best supports it. All the all the interventions out there all the transformations that we've been working on so hard for the last decade to fix primary care, all fell out the window when COVID-19 hit because they were based on specific payment models. And COVID-19 doesn't care about payment models and everything fell apart. Let's not let the crisis go without taking advantage of it. Let's understand what it's shown us. We've been doing it the wrong way. Let's not do a patchwork until COVID-19 goes away and then go back to the way it used to be.

Let's understand that our fragmented system doesn't work. We should be favoring the connections among primary care, public health and behavioral health. That's what people need the most. And we need to be able to talk to each other. We have no database for primary care, no national database for primary care, when COVID-19 hit, where were we to go to understand the prevalence of COVID-19 in primary care? Where were we to go to understand which cities which states were being hit the worst? Where are we supposed to go to understand how practices are suffering and which practices are closing or what's happening to patient volume? We struggled to be responsive because there is no national resource for that. We need to fix that we need something like the ONC (Office of the National Coordinator for Health IT) but for primary care.

Medical Economics: What does the healthcare system need to do to address these inequalities? And also, what's the role of primary care in addressing those inequalities?

Etz: This is an area in which primary care has focused a great deal of attention. Health inequities are extreme and in the U.S., they continue to grow. It's not only because of what happens in healthcare, it is because we have actually created a national infrastructure that it supports and promotes structural racism. We have to change that.

So one of the things we do in primary care when we say we pay attention to the whole person; you bring with you your biography as well as your biology. And we hold those two things in common to each other when we address how your health is won and lost. We know that there are people who systemically have different experiences based on all kinds of social markers. The color of your skin is one of the most visible and therefore one of the most frequent, but there are lots of other markers that we also use to define people into categories. And then to structure their experience around those categories, often two detrimental ends.

So in primary care, we pay attention to what's happening because people who experience any kind of systemic equity actually experienced that as a health burden. It causes a difference in their body's ability to adjust to the natural And biological environment, it causes an added burden to their ability to defend their body against diseases. And it adds to the health burden and the stresses on the system, which can wear out many of our defenses. Primary Care is particularly tuned to that, and so pays a lot of attention to what sorts of social demographics each patient has so that we can know what's likely to be causing them more distress so that we can work with them to address it. And sometimes that means connecting them to Area Community Resources. Sometimes that means helping them with language, obstacles to accessing care. It can mean a lot of things. But we have in real need to understand that we also in addressing disparities have a need to explain and educate to policymakers and insurance And the public that this is not simply named calling that there is a real and fundamental damage and violence done to people who experience systemic inequities every day.

The fact that we see right now a lot of protests going on is because people are tired of it. They're angry about it and they have a right to be. So as primary care, we need to be leaders in explaining what the health impact is to people who suffer such conditions. And when I say they suffer conditions, I don't mean that their identity is a condition they suffer. I mean, they are suffering the conditions that are accepted by the structural inequities in our society.

We need to explain to our policymakers and leaders what the impact of those are in very real terms, so that we can work together to alleviate them. Sometimes alleviating them means in Not designing care specific to different groups of people, but rather saying we're all people, we all have a right to dignity and humanity, we all have a right to pursue fulfillment. And it is our job as primary care to help you be the best that you can be in whatever way you choose.

Medical Economics: It's easy to be pessimistic about some of this stuff. So I'm wondering if you can envision for us what the primary care practice of the future should look like?

Etz: That's a great question. I spend a lot of my career these days actually trying to answer that question. And I gotta tell you, I get some of my best inspiration from people that I talk to, despite all the craziness that's going on.

I talked to a doctor the other day who said when the pandemic started, the first thing she did was realized her staff were going to wonder about whether or not they had jobs. So she looked at her patients and determined which ones of them were likely to not be able to pay for their bills. And she figured out how much money they were going to lose, and then how much money they would have to pay for staff and she let them know all right away, you're going to be safe, we're going to do fine. The next thing she did, and this is not only heroic right now, but actually something we can do in the future and part of primary care in the future. Because she knew her patients. She could actually read down the thousands on her patient panel, know which ones were at financial risk, and she called them on the phone. And she told them, ‘We know you're at financial risk. If you don't have the ability to pay, we still want you to come in, we'll forgive whatever bills there are.’

Being able to back up your patients is an incredible thing to be able to do. And in case you think this is just a pandemic thing, I actually did a study for the Robert Wood Johnson Foundation, identifying a set of 200 exemplary primary care practices across the country. This was a common thing they were doing. There were lots of practices that were saying, ‘Look, if you don't have money to pay, but you just had a baby and you want to take parenting classes. You didn't get a high school degree and you want to get your GED or you want to do some volunteer work. Go ahead and do that stuff. Report to us how many hours you spent doing it, and we'll credit your bill for that.’ 

And they told me everybody started coming in. Of course they did. And what they told me because I really will never forget it is, ‘Rebecca, it turns out if you invest in the community, they invest in you.’

Let’s go a bit deeper: So every business carries a certain debt load, when you have bills that patients can't pay, so you carry it. During the Great Recession, the practices that we're doing that thing I just told you about had the lowest debt load in their 30-year history, which is exceptional, because the community was interested in investing in the practices that had invested in them. And I think that's what you'll see in the future of primary care.

The future of primary care is not going to be about what's better family medicine or internal medicine. And it's not going to be about which payment model is better, a bundled payment or a capitated payment. It's not going to be about who has the best technology. It's going to be about having relationships with people, and understanding that people need to be routed to a place and they need to be able to go somewhere that they can trust, that they can feel vulnerable and get advice and trust that that person puts the patient's interests above their own. That's what primary care does.

Our future primary care offices are likely to do that with different kinds of staffing structures and with different kinds of tools. But the best of them are not going to be fascinated by the models, the best of them are going to be fascinated by social connection.

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