Tuesday, Jan 10, 2023

The Solution to America’s Primary Care Crisis

Dr. Sara PastoorDirector, Primary Care Advancement, Elation Health


Primary care in the United States is on the brink of collapse. Primary care providers suffer existential burnout, are the lowest compensated of all medical specialties, and there is a crisis-level shortage of primary care physicians, especially in health professional shortage areas. Despite strong evidence linking primary care (unlike any other medical specialty) to better quality of life, longer life expectancy, better patient experience, and lower total cost of care, primary care has been undervalued and under-resourced for many decades, marginalized by an industry dominated by expensive subspecialty care, lucrative procedures, and a dysfunctional third party payer system which has rendered the patient a commodity.  

In a report published by the Commonwealth Fund and released in August 2021, performance of the U.S. healthcare system was compared to that of other high income countries. The results were stunning. 

Despite investing far more of its gross domestic product on health care, the U.S. ranks dead last overall, and last on access to care, administrative efficiency, health equity, and health care outcomes. There were four key features which were characteristic of the top performing countries and which distinguished those countries from the U.S. One of those four features was that they invest in primary care.

The primary care that most patients (and primary care clinicians) experience today is rushed, fragmented, disorganized, delayed, diluted, and ineffective. A widely held belief is that the fee-for-service payment model of U.S. health care is at the root of this bloated, dysfunctional, poor performing delivery system, and it has been particularly toxic to the delivery of high value primary care. Yet, there is good evidence that primary care has the power to restore the health of our communities, close gaps in health equity, and drive down wasteful and preventable health care spending. But how to get from here to there, considering our under-resourced, under-performing primary care system, crippled by the wrong payment model?

Enter the Direct Primary Care (DPC) movement in primary care. In this model, primary care providers (PCPs) step away from fee-for-service insurance billing, which brings with it administrative burden, increased financial overhead, and an emphasis on transactions and procedures at the expense of powerful clinical relationships between PCPs and their patients. In the DPC model, PCPs are paid a consistent fee through a retainer (or membership) program, often paid either by the patient or by a self-funded employer looking to innovate on their health benefits design. This prospective payment design both financially and operationally liberates the PCP to spend more time on patient care, to provide same day/next day access, to deliver comprehensive care, and to coordinate care across the complex health care spectrum. At the nucleus of this model and its success is the PCP-patient relationship.

Without insurance rules, complex billing and reimbursement processes, or other regulatory burdens, PCPs are liberated to practice their craft as they see fit. But beyond this freedom, they are also incentivized to do what’s best for the patient, because the success of the patient is central to the success of the business. With the incentives aligned and the freedom to do what’s best for patients both clinically and financially, patients win - not because of heroic efforts to overcome obstacles, bureaucracy, and dysfunctional systems, but by design.

We stand at an inflection point - one where we have an opportunity to lean into the DPC model and away from a legacy health insurance system, which has been extravagantly lucrative for those in power in the industry, but of limited benefit to society. The crippling and decimation of American primary care has benefitted hospitals, heart surgeons, and health plans alike, but has driven infant mortality rates up and life expectancy down in a country which spends double on healthcare compared to peer nations. We cannot afford to continue repeating past mistakes - it is time for change.

The subspecialty-heavy, hospital-driven, bloated and underperforming U.S. healthcare system needs robust, high functioning primary care. The evidence for more primary care is clear. How we achieve the goal remains poorly defined. DPC has shown us a way, if only we’d take it. 

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