The Front Line for U.S. Health Care is Primary Care: Threatening to Some, Opportunity to Others

Last week, an important study found that a higher number of primary care physicians (PCPs) in a community is associated with significant gains in life expectancy and improvements in mortality rates.

Based on data from 2005 to 2015, an extra 10 PCPs per 100,000 population resulted in a decrease in mortality rates from cardiovascular disease by 30.4 deaths per million; cancer by 23.6 deaths per million; and respiratory by 8.8 deaths per million.

The researchers noted that “in adjusted mixed-effects regressions, every 10 additional primary care physicians per 100 000 population was associated with a 51.5-day increase in life expectancy whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase.”

Their findings are based on an analysis of changes in primary care and specialist physician supply from 3142 US counties, 7144 primary care service areas, and 306 hospital referral regions. To most, the research team’s conclusion is not a surprise.  Most policymakers and industry wonks acknowledge that primary care is key to better health and lower costs. But for many incumbents in the industry, it’s problematic.

Context: The Six Facts that Matter Most

1.The supply of primary care clinicians is shrinking. From 2005 to 2015, primary care physician supply relative to population decreased from 46.6 per 100 000 population to 41.4 per 100 000 population with greater losses in rural areas. According to the Association of American Medical Colleges, shortages of primary care physicians and nurse practitioners will be between 7,300 and 43,100 physicians by 2030. AAMC

2. Costs associated with chronic diseases—a primary focus in primary care—are increasing. They’re 90% of total U.S. health spending today. “The fastest way to lower costs, or at least to slow the upward spiral, is to reduce the number of Americans who carry excess weight, smoke, or drink too much alcohol. The share of American adults classified as obese increased from 13% in 1960 to almost 40% in 2016. Another 33% are overweight.” National Center for Chronic Disease Prevention and Health Promotion, Milken Institute

3. The U.S. spends considerably less for primary care compared to other developed systems. Primary care services are 5-7% of total U.S. health spending: by contrast, they’re 12-14% in other developed systems that spend substantially less on healthcare overall and get equivalent or better outcomes. Patient Centered Primary Care Collaborative, World Health Organization

4. Primary care is not as lucrative as specialized care. In 2017, general internists earned between $268,401 and 278,946, pediatricians between $252,617 and 264,261, and family physicians between $260,725 and $266,562. By contrast, orthopedic surgeons earned between $609,439 and $632,066, invasive cardiology between $624,120 and $625,180, urologists between $469,667 and $494,020, and so on. And these comparisons don’t include side deals enjoyed by many specialists—partial ownership of a surgery center or diagnostic facility, or in many communities, prestige. Sullivan Cotter

5. Most primary care clinicians (80%) are employed by hospitals, insurance companies or large medical groups. Younger PCPs just out of training have multiple offers: family and internal medicine are the most in-demand job openings. But employment doesn’t equate to career satisfactions: most are less satisfied than their independent peers and earn less. Not surprisingly, they’re receptive to offers from other employers where compensation is competitive and work-life balance is assured.   Medscape, Doximity, Geneia

6. Investments in effectively-designed primary care improve health and reduce costs. In Rhode Island, investment in primary care increased from 5.7% to 9.1% over a four-year period. Costs went down 14% and health status improved. That’s why employers, insurers, private investors, entrepreneurs and hospitals are taking a fresh look at primary care. Patient Centered Primary Care Collaborative, RockHealth, Venture Wire

None of this is news. Hospitals know it. Primary care physicians know it. Specialists know it. Consumers know it. Employers know it. Investors know it. Policymakers know it. Primary care is a hot commodity. But is primary care positioned to achieve its highest and best value? In most communities, it’s still a step-child to specialty care. Here’s why:

Incumbents, especially hospitals and specialty providers, have a vested interest in protecting the status quo. Fee for service payments to providers still dominate revenues. Controlling referrals to hospital loyal specialists and clinical programs to generate revenue is the primary rationale for PCP employment by hospitals, and the rationale for PCP employment by insurers and private investors is to make sure the referrals are sent to low cost providers. Ironically, the potential to reduce demand, improve health and lower costs by aggressively managing population health has not been the priority.

Primary care has failed to operate as a unified movement. The Patient Centered Primary Care Collaborative, founded in 2006, is an admirable effort. Professional societies—AAFP, ACP, AAP and others– have advanced notable policy recommendations and sponsored impressive pilots. But regretfully, a unitary voice of primary care is missing. The nation’s primary care safety net providers—community health centers, school clinics, FQHCs et al– operate outside the purview of services offered by local hospitals. General dentistry and mental health counseling aren’t members of the club. Food pantries and senior services are more typically framed as United Way efforts than community-based primary care. As a result, primary care, in the U.S., operates in two parallel tracks: one for those who have occasion to visit a physician’s office, and another for those that can’t afford or otherwise avoid them.

Is it likely to change?

Yes. Four trends suggest the landscape for primary care is changing:

1. Consumers are embracing a broader concept of health. The majority of U.S. consumers understand that prevention and primary care are positive investments in their personal health. They express willingness to use apps to navigate their health and interact with health coaches: that’s the rationale behind Apple’s big bet on its Health Watch, CVS-Aetna’s expansion of its clinics and others. And “food as medicine” is gaining traction: provider organizations like Geisinger’s Fresh Food Pharmacy, Kaiser’s Thrive Kitchen and others, and insurers like Blue Cross of Massachusetts’ Community Servings are mainstreaming nutrition into their primary care strategies.

2. Employers are integrating primary care services into their work places and equipping them as gatekeepers. More than half (54%) of large employers had an on-site health center in at least one of their larger sites in 2018 and another 11% are considering doing so by 2020. It’s simple: employers resent being saddled with higher costs because Medicare pays only 91% of actual hospital costs. They’re investing in primary care and expanding their wellness offerings to reduce utilization and refer specialty care to high value providers. National Business Coalition on Health, MedPAC, Anthem

3. Private investors are making big bets in primary care. There are currently 2800 retail clinics, 8774 urgent care clinics and countless alternative providers that offer primary care services: most are funded by private investors. And private investors are banking start-ups like Eden Health, Privia, CareMore, OneMed, Iora Health, Aledade, Parsley Health, Sheerpa, Aledade, Brio Systems and others: each leverages a unique blend of telehealth, health coaching, analytics, holistic therapies, unique payment models and customer service to challenge traditional practitioners and disrupt traditional referral patterns.

4. States are emphasizing primary-care. States like Rhode island, Vermont, Oregon and others are legislating increased investment in primary care. In the 36 gubernatorial races last year, healthcare was the biggest concern to voters, especially budget hawks fearing fiscal default and populists advocating for Medicaid expansion. A holistic model of primary care is the mechanism whereby a state can reduce its health spending and improve the health status of its citizens, but it’s not without risk. Doubling down on primary care is sure to draw the ire of some who are threatened.

My take

Recently, Adam Boehler, Director of the CMS Center for Medicare and Medicaid Innovation, promised to “blow up” office visits to primary care clinicians suggesting a new incentive is under consideration. Secretary Azar has promised to overhaul Medicare accountable care organizations to hold them accountable for cost savings: primary care effectiveness is the key. Amazon, Humana, CVS, Apple and other big names have announced major innovations in primary care as the focus of their employee health strategies.

Per the JAMA study, the fact that increased primary care correlates to better health is not a surprise. The key takeaway is how the health system responds. Traditional players are prone to acknowledge the importance of primary care while guarding their sectors from encroachment. By contrast, a new breed of primary care players is boldly advancing new models that have the potential to fundamentally transform the system as we know it.

Primary care is no longer a step child to specialty care nor is its scale and scope limited to conventional physical medicine. It is bigger. It is the frontline in the battle to improve health and lower costs. That’s threatening to some but opportunistic to those making big bets on its future.

Paul

PS This week, I go under the knife. I trust my doctors and the hospital is among America’s highest rated and most wired. Ironically, I can access my medical record and communicate with my clinicians electronically, but when I asked what my procedure is likely to cost—even within a range–the reply was disappointing. “Your insurance will pay most of the it.” So much for price transparency, person centered care and the new age of healthcare consumerism! We have a long way to go.

Basu et al “Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015” JAMA Intern Med. Published online February 18, 2019 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2724393