Oct. 20, 2023 Updated Sat., Oct. 21, 2023 at 10:10 p.m.
By Frances Stead Sellers
Washington Post
When it comes to saving American lives, don’t look to cardiologists, oncologists or even the made-for-TV heroes in the ER. It’s primary care providers who offer the best hope of reversing the devastating decline in U.S. life expectancy.
That’s the conclusion reached by experts who study America’s fractured health care system.
A 2019 study based on U.S. population data and published in JAMA Internal Medicine found that every 10 additional primary care physicians per 100,000 people was associated with a 51.5-day increase in life expectancy.
That finding comes after decades of research – and mounting frustration – from health-system experts who have argued for more investment in the accessible, comprehensive, community-based services that allow countries with far fewer resources, including Chile, Costa Rica, and Portugal, to make gains while the United States founders in the survival stakes.
Without patients having access to primary care, minor complaints evolve into chronic illnesses that demand complex long-term treatment plans. Addressing basic patient problems in the emergency room costs up to 12 times what it would in a primary care office, resulting in billions of additional dollars each year.
But even as evidence mounts that access to primary care improves population health, reduces health disparities, and saves health care dollars, the field is attracting fewer and fewer medical students. The remaining small-group medical practices are being replaced by concierge offices with steep annual membership fees.
In response, the Department of Health and Human Services is making a commitment to strengthen primary care for all Americans and has been soliciting input from health care providers, unpaid caregivers, health technology developers and others to establish what role the government can play. And in September, Sens. Bernie Sanders, I-Vt., and Roger Marshall, R-Kan., announced a $26 billion bipartisan bill aimed at expanding primary care and reducing staffing shortages.
Meanwhile, the business of primary care is in upheaval, with investors banking on integrating the historically fragmented industry with pharmacy and specialist care.
Giant retailers including Amazon, CVS and Walmart are spending billions of dollars to enter the market, promising to transfer their trademark online ordering and one-stop shopping to primary care. And venture capitalists are investing rapidly in value-based care, a model that reimburses providers based on positive outcomes rather than rewarding them for treatment they offer after patients fall sick.
All of which puts a big question mark over the future of primary care.
“Who is going to win this race? I don’t know,” said David B. Nash, a physician and professor of health policy at the Jefferson College of Population Health at Thomas Jefferson University in Philadelphia.
“Can America improve health? That’s the key question.”
The problems undermining primary care were exacerbated by the coronavirus pandemic, according to a report by the Commonwealth Fund, a nonprofit that supports research on health care issues. But the erosion had been underway for years. From 2005 to 2015, the prevalence of primary care physicians in the United States fell by 11%, from 46.6 to 41.4 doctors per 100,000 people. Many primary care physicians are specializing as hospitalists, who coordinate inpatient care. Pediatricians are picking subspecialties such as neonatology or pediatric cardiology. A recent JAMA study shows that fewer than 9% of third-year internal medicine residents are interested in primary care careers.
“The income gap has a big effect on those folks,” said Robert L. Phillips, a professor of family medicine at Georgetown University and executive director of the Center for Professionalism and Value in Health Care. For medical school graduates whose educational debts can soar to $200,000 or more, the financial allure of being a specialist is clear: Neurosurgeons make close to $1 million in peak earning years, while family-practice physicians earn about $230,000, recent figures from the National Bureau of Economic Research show.
The upshot of increasing specialization is that the United States, which spends more per capita on health care than any other country, is devoting a decreasing proportion of those dollars to primary health care, falling from 6.2% of total health spending in 2013 to 4.6% in 2020. The 38 member nations of the Organization for Economic Cooperation and Development spend a far greater percentage of total health care dollars on primary care, with one estimate reaching as high as 14% in 2016.
About 100 million Americans live in regions the government has labeled primary care workforce shortage areas. The deficits are most acute in rural America, where hospitals are shutting down.
That means fewer practitioners of family medicine, internal medicine, pediatrics, geriatrics and even gynecology and obstetrics, who are often included in the category of primary care.
Numerous studies show that medical treatment has a far smaller impact on health outcomes than a person’s education, environment and, above all, behavior – the social determinants of health that a community-based primary care network, complete with nurses and social workers, can help change.
And while urgent care centers may provide efficient relief for sprained ankles or the flu, they are not equipped to act as disease detectives, spotting signals in a familiar patient that indicate the difference between an upset stomach and incipient diverticulitis. Several recent studies have shown that the continuity of care that a family physician provides reduces early mortality.
“The evidence is clear,” said Christopher F. Koller, president of the Milbank Memorial Fund, a foundation devoted to improving population health. “If we want to improve life expectancy, we’ve got to help people to have a relationship with someone who has the clinical skills to help them.”
But there’s little institutional recognition of the role family physicians can play in persuading sometimes reluctant patients to do what’s best for them. During the pandemic, Phillips said, when coronavirus vaccines were distributed largely through pharmacies and at mass-vaccination centers, family physicians were robbed of the opportunity to give the shots – right there and then – to patients who came in for routine appointments.
Since World War II, policymakers from both parties have debated the role that state and federal governments should play alongside private insurers to protect citizens from falling sick, often encountering cultural – and therefore political – resistance to their ideas.
Americans have consistently resisted restrictions on their choice of provider, preferring to seek their own specialist care rather than have it mediated by a primary care provider. The country’s belief in market forces supports the predominant fee-for-service model, which compensates doctors for performing procedures on sick people rather than preventing people from falling sick.
Since 1973, companies with 25 or more employees that provide traditional insurance plans have been required to offer the option of a health maintenance organization – HMO – whose name reflects the very goal of keeping people well.
But prospects for those organizations, which typically require a patient to choose a primary care physician, are unclear. One of the largest, Kaiser Permanente – a nonprofit that acts as the insurer and the deliverer of care and operates in California and seven other states and D.C. – recently purchased Pennsylvania-based Geisinger Health to create a nonprofit, Risant Health, promising to expand the values-based model on the East Coast, where Kaiser had been less successful. In October, in a sign of widespread employee dissatisfaction, more than 75,000 Kaiser health workers and support staff staged a three-day strike for higher pay and better staffing.
Nash’s own institution, Jefferson Health, one of four major academic medical centers in Philadelphia, bought a managed care plan, Health Partners Plans, in 2021. The purchase, Nash believes, is likely to have an impact on what the medical school teaches.
“It will influence our training to refocus on improving health,” said Nash, co-author of the recent book “How Covid Crashed the System.”
But the biggest shifts underway may be among retail behemoths.
Pharmacy giant CVS, which acquired the insurance company Aetna in 2018 and has already equipped itself in select stores with nurse practitioners stationed in MinuteClinics, recently bought the primary care chain Oak Street Health in an almost $11 billion deal that will give it control of medical centers for older adults in more than 20 states. Amazon has bought One Medical, a company not profitable on its own, promising to make it easier for patients to find affordable products and professionals. (Amazon founder Jeff Bezos owns the Washington Post, and the news organization’s interim CEO, Patty Stonesifer, sits on Amazon’s board.)
There are clear financial incentives for such vertical integration: Primary care acts as the gatekeeper to the health care system, influencing where a patient’s subsequent needs – from pharmaceuticals to surgeries – are met, making it inviting for a company to control those successive steps.
But many health system experts believe a broader government-led effort is needed if the goal is to give all Americans access to primary care and reverse the downward trend in life expectancy.
“The market isn’t going to work. This is a public policy issue,” said Koller, who worked with Phillips on a May 2021 report for the National Academies of Sciences, Engineering, and Medicine on implementing high-quality primary care.
The report’s key recommendation is to shift away from America’s fee-for-service system to a model that rewards primary-care teams for looking after people. It calls on the Centers for Medicare and Medicaid Services, which drives much of the health care marketplace, to increase the overall portion of its spending going to primary care. The report also charges HHS with providing accountability.
In response, HHS in 2021 announced an Initiative to Strengthen Primary Health Care, promising an action plan in 2022.
That plan has not materialized. And in July, global health experts who met in Washington to share expertise on the role primary care plays in bolstering health security took the opportunity to push for the promised federal plan.
The dominant market forces in the United States struck many at the conference as antithetical to the models that prevail overseas, said Bob Mash, chair of the department of family and emergency medicine at Stellenbosch University, who recalled feeling renewed pride in South Africa’s primary care system, with its emphasis on the common good.
In an emailed statement in September, HHS said the office of the assistant secretary for health has assembled 14 HHS agencies to “brainstorm and coordinate” its efforts, which would be “bound by our current statutory authorities and funding.”
HHS promised a published summary and a new Primary Care Dashboard that will “monitor the health of the primary care system and the impact of actions that HHS takes to strengthen primary care.”
But not quickly enough to keep up with the market, said Nash, the Jefferson physician.
“The public sector is going to be behind by definition,” he said. “That’s a big challenge when American lives are at stake.”
