When people cross a bridge, they take its stability for granted. They don’t consider it might collapse. So should it be in healthcare. Whether a patient or a family member is trying to stay healthy or manage a chronic condition, they need reliable partners to navigate an uncertain and risky passage.
Primary care is healthcare’s foundation and the only part of the system associated with longer lives, improved health outcomes, and reduced racial and ethnic health disparities. Relationships with a primary-care doctor can last a lifetime. A worried parent, the adult child of a frail elder, or someone facing troubling symptoms understands the comfort of a clear treatment plan and reassuring words from someone who knows their values.
Yet primary care is under threat in the U.S. just when we need it most, according to a new report from the National Academies of Sciences, Engineering, and Medicine. Compared to other countries, U.S. primary-care clinicians are overworked and under-supported. They provide one-third of all medical visits but receive only 5% of payments. Meanwhile, the workforce is shrinking, with more clinicians retiring or moving into more lucrative specialty areas.
Thousands of community practices are being acquired by hospitals and health systems. The financial pressures of COVID-19 will likely accelerate this trend. So, if we are to rebuild the foundation of primary care in the U.S., hospitals and health system executives must play an active role in leading this change.
This starts with aligning financial incentives. A health system willing to uphold a stated commitment to population health with population-based payment systems must acknowledge primary care is severely undervalued, as the report states. To achieve high-quality primary care, health system leaders need to shift more resources and attention to it.
Institutional leaders will then treat primary care as a core part of a comprehensive population health strategy, not as a source of referrals to higher-margin services. They will design primary care around the evolving needs of their communities. For example, a pediatric-focused health system might invest more heavily in partnerships with Head Start centers and local public schools, while a system that largely serves older may focus on partnerships with faith-based organizations and long-term care facilities.
Broadly speaking, the National Academies report says primary care should be a common good, available to every individual in the U.S. Strengthening primary care should be a policy priority in five areas:
- First, we must insist on comprehensive, team-based care that is fully accessible at any time and in any setting. And we must pay for primary care on a per-person basis to incentivize taking care of people, not just providing visits. As the country’s largest payer, Medicare must lead this fundamental reordering.
- We must expect and ensure that every person in the U.S., regardless of insurance status, has a usual source of care. When hospitals, health centers, and primary-care practices treat people who are uninsured, they should assume and document an ongoing clinical relationship with them.
- We should train primary-care clinicians in teams, where people live and work. Currently Medicare foots most of the bill for training physicians to be overworked hospital foot soldiers—even though most primary care takes place in community settings. The Teaching Health Centers program should be expanded to rectify this mismatch and more than $15 billion federal funding for training doctors should favor community and rural locations
- Proprietary health information technology systems have created more barriers to information sharing and more work for providers and patients. The next round of federal certification standards needs to make sure heath data are available where and when it is needed for care, not hoarded as a source of profit.
- Finally, we need transparent, public accountability measures to ensure the critical work gets done. The HHS secretary should have an interdepartmental council to oversee federal primary care initiatives. Health system leaders should be preparing for new payment models that enhance primary care’s capacity to deliver on population health and for measures that monitor their success.
Just like our roads, bridges and water systems, primary care is used daily and affects the health and economy of our nation. Public- and private-sector leaders must seize this moment to lay a stronger foundation of primary care and give it the rehabilitation, investment and policy attention it deserves.