Primary care should be the center of gravity in health care [PODCAST]

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“If we want a more effective health care system, it needs to be re-engineered to revolve around the true center of gravity – the patient. We must involve patients early and often in the design of health policy, health technology, and health care ecosystems. We must reinvent health care payment models to tie incentives to what is of value to patients. And we must give every American access to a high-quality PCP.

Until we do this, we’ll continue to pay too much money for too little value, and we’ll all suffer in a system perfectly designed to keep getting the results it’s getting.”

Sara Pastoor is a family physician.

She shares her story and discusses her KevinMD article, “The center of gravity in health care and the role of primary care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show, we have Sara Pastoor. She is a family physician. She wrote the KevinMD article “The center of gravity in health care and the role of primary care.” Sara, welcome to the show.

Sara Pastoor: Hi, thanks for having me. I’m so excited to be here with you.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Sara Pastoor: Yeah. So I started my medical career in Army medicine, actually. My first duty assignment was at Brooke Army Medical Center in San Antonio, and I stayed in Army medicine for about 15 years. I was so fortunate to take that path, because it gave me the opportunity to learn both clinically and in leadership roles, which I otherwise would never have had in the private sector, I think. And it set me up really well for the rest of my career.

After leaving Army medicine, I took a quick detour into academic medicine and then went to work for an employer-sponsored, innovative primary care program. I have had really great opportunities to work in innovative primary care models my whole career, with integrated teams and a very patient-centered focus, and so I have really enjoyed being able to practice in that style. Today, I practice part time in a direct primary care clinic, and my full-time role is as the director of primary care advancement at Elation Health, which is an EHR that is focused on making primary care successful.

Kevin Pho: One of the things that you mentioned is that working in an Army setting taught you leadership skills that you may not have learned in the private sector or otherwise. What kind of leadership skills did you learn?

Sara Pastoor: I think I really had a very up-front seat to the total health system and had the opportunity to receive mentorship from very experienced health care leaders and physician leaders in that environment. I was able to really learn from the very best and understand deeply the business of medicine, for better or for worse. I just don’t know if I could have had that kind of perch in terms of a systems approach to health care and the opportunity to find my way into every single aspect of health care: quality, credentialing, metrics, you name it. I got involved, and where else would I have been able to do that?

Kevin Pho: One of the other things that you mentioned is that your full-time role is with an EHR company, and as you know, EHR companies have a certain perception among practicing clinicians. Are there any misconceptions that you’d like to clear up from the perspective of the industry?

Sara Pastoor: I think that in order to make an EHR do what clinicians need it to do, in order to make it intuitive, in order to make it work for you instead of you working for it, that takes a lot of investment on the part of the EHR company. You really have to hire the right talent. You have to spend a lot of time doing due diligence on discovery of the workflow and how clinicians operate in the workflow. To do that costs money.

And there are so many EHRs out there, particularly in the ambulatory setting, where there isn’t a lot of extra money to spend, that are just competing on price, and so they therefore are not really competing on the quality of the product. You get what you pay for, right? So in order to deliver a really good EHR that serves the clinician well, you have to spend a lot of time investing in a lot of talent and investing in how you design that product. And in order to afford that, you’ve got to find other ways to invest in your product. So it’s a tricky business, and if you aren’t willing, as a user, to invest a little bit more money to get a quality product, then you’re going to make your life more difficult.

Kevin Pho: All right, let’s transition into the KevinMD article that you wrote. It’s titled “The center of gravity in health care and the role of primary care.” Now, for those of you who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Sara Pastoor: Yeah. So in this role at Elation, I’m paid to write a lot, and this is the first time I’ve had a role like that. What I’ve noticed is that to write, you really have to sit and reflect, and all the things that I’ve been writing about have had this common theme bubble up for me: In our health care system, we talk about patient-centeredness quite a bit, but we really don’t understand it very well, and we really haven’t come to a point where we can understand it deeply.

As a direct primary care physician, I’ve been able to see what I consider to be probably the purest form of patient-centeredness, because the DPC model is really a rogue operation. They’re operating at the fringes of the health care system by design and outside of the traditional payment system. So the physician is not working for an insurance company. They’re not working for an employer. They’re working for the patient. And when we work for the patient, we’re going to do everything we can in the patient’s best interest, and the dividends that pays are really remarkable.

Systemically, across U.S. health care, we really have not come to a point where we are putting the patient in the center. When we look at the health care landscape, the patient is the most peripheral part of health care, sort of an afterthought in how we design and deliver health care. In the direct primary care model, we see the patient right in the center of the spotlight, and that’s where the patient should be. Health care is about the patient. And so I really wanted to write and talk about how very important it is to pull that patient out from the periphery and back into the center, what that would look like, and then why primary care plays such a critical role in making that patient-centered equation happen.

Kevin Pho: Now, can you tell us a story or a case study of how patient-centeredness is in fact at the center of direct primary care, and maybe contrast that scenario with, say, a traditional payment model?

Sara Pastoor: Let’s see. So in the direct primary care model, for example, it goes so far beyond spending adequate time with the patient, really getting to know the patient, and being accessible to the patient 24/7. All those things are a critical part of direct primary care, and something that we don’t see in traditional fee-for-service. But it really goes way beyond that, because we really see primary care physicians partnering with patients on the true underpinnings of what’s affecting their health.

That could be something like they’ve got a hospital bill that they cannot pay, and the PCP will literally call the hospital and bargain with them to get that bill down to something that the patient can afford, so they don’t wind up in crippling debt. Nowhere else do we see that in health care. So I think that in the direct primary care model, we’re really opening up the opportunity for patient and PCP to be deep in this powerful healing relationship. That lends itself to patients really becoming more engaged, understanding their health better, and being able to take accountability for their own health, instead of just being this passive recipient of health care services that are just being tossed at the patient. And then they walk out of the exam room, and they don’t really know what to do, and they can’t remember everything that was said, and they can’t get access to the physician again to ask questions. It’s just such a stark contrast.

Kevin Pho: What do you see as the role of direct primary care? Because we’ve had several direct primary care physicians on the show and writing for my blog, and I think that they all have varying responses in terms of what they see as the role of direct primary care. Some see it continuing to play a niche market; some people want it to replace primary care as a whole. But I just wanted to ask you: In terms of the next few years, what do you see as the role of direct primary care?

Sara Pastoor: Yeah, that’s a great question. I’ve actually been thinking about that question myself recently: Where really are we going with this? I think, if nothing else, direct primary care shows the power of predictable up-front cash flow in primary care and how the fee-for-service payment model is so toxic. So if we can use the DPC model as an example of how to heal our health care system, by investing in primary care and by putting the patient at the center of what we’re doing, and follow that and find other ways to also continue to do that with prospective payment, then I think the DPC model has done its job.

It changes everything, not only for the patient but also for the physician. I was talking to a DPC doc yesterday who told me, “My administrative burden, switching from a fee-for-service delivery system into DPC, went down by 95 percent.” I mean, it’s just a huge relief, and they really get to do what they trained to do, which is partner with patients and really work on their health. Everyone wants that. There’s such huge value there. So should we have that replace all of primary care? That’s probably not feasible, although many employers are starting to contract directly with DPCs. But I think it’s definitely starting to show the value.

Where we need to go next is to start to study direct primary care and its outcomes and impact on the total cost of care, because there really is a paucity of literature about that. So that’s something that we’re working on. Elation is trying to create that evidence, so we can tell the stories and show what the true value of primary care can be. Because even in prospective payment systems from insurance companies, we’ve got the insurance company defining what value is and telling the PCP, “These are the metrics that you need to meet.” In the DPC model, they have been relieved of all of that. There’s nobody telling them how to deliver care or what value is. They’re just doing it, and they are internally motivated and passionate about delivering that value the right way for patients, and it’s creating way more value than we see in any other primary care model. We just need to tell that story.

Kevin Pho: I always have a question about access. We already have a primary care shortage, and a lot of patients can’t find primary care clinicians in general. Direct primary care clinicians see fewer patients and, of course, spend a longer time with patients, but that brings us to that tension between the amount of time they spend with patients and the lack of access. So, speaking from the perspective of direct primary care, how do you reconcile that problem?

Sara Pastoor: I love this question, because the answer to solving the shortage problem is not for primary care physicians to see more patients. We already know that that is the broken road. The answer is to create a better model of primary care that primary care physicians will enjoy. That model of having to take care of 2,500 patients each has created an inhospitable career field, and we need to make it hospitable, right? We need to make it a career field that people want to choose. And so if we can entice more graduating medical students into primary care specialties, then we can fix the shortage. So the answer is not that PCPs see more patients. The answer is, let’s have more PCPs.

Kevin Pho: We’re talking to Sara Pastoor. She’s a family physician. She wrote the KevinMD article “The center of gravity in health care and the role of primary care.” Sara, how difficult was it for you to start up your direct primary care practice? I know that this is of interest to a lot of clinicians who are in traditional practices and, say, want to transition to a direct primary care model. How difficult was it for you to start up your own practice?

Sara Pastoor: To be honest, because I’m juggling a full-time job and the DPC practice, the on-ramp for patients has not been fast for me, and so it’s been growing very, very slowly. I haven’t put a lot of effort into marketing it, because I’ve been so focused on my day job. But I was very fortunate to do this with partners, people who were maybe a little bit more entrepreneurial than me. I have the business background, but I don’t have the entrepreneurial spirit to do something like this on my own.

And I think those two things are actually probably the biggest barriers to other physicians going into the DPC model, because we don’t train physicians in medical school or residency in the business of medicine, and we don’t encourage them to cultivate that entrepreneurial spirit and give them the tools that they need to go out there and do something brave like this. And it really does take a lot of courage. So I’d love to see us build more of that into our training programs, so that we can prepare physicians well to choose independent practice, even if it’s not the DPC model. Even if they go into independent practice that’s insurance-based, we’ve got to preserve that independent practice model in our communities and get out of this consolidation and employment model just because that’s the path of least resistance.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Sara Pastoor: I think I want to say that primary care is so incredibly critical to the success of our health care system, and anybody who disagrees with that doesn’t understand primary care and doesn’t understand the economics of health care. Primary care is the only medical specialty that improves outcomes, increases life expectancy, and decreases the total cost of care while also improving patient experience. No other medical specialty can boast that.

And if we compare the United States health care system to peer nations, we see how dismally our health care system is failing. One of the key things that makes those other health care systems more successful than ours is that they invest heavily in primary care systems. So we’ve got to start investing in primary care in this country and restoring primary care to its powerful role in the health care system, if we want the health care system to stop failing us.

Kevin Pho: Sara, thank you so much for sharing your time and insight. Thanks again for being on the show.

Sara Pastoor: Thank you. Take care.

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