An excerpt from Wonderful and Broken: The Complex Reality of Primary Care in the United States.
In a health care system full of paradoxes, this is perhaps the most striking. Primary care delivering value-based care is seen by many as the solution for an inefficient, inequitable, and poorly-performing health care system. Yet it is a shocking mess of burnout and depletion. With all the radical intention of Lenin, we must ask, “What is to be done?” Fortunately, there is no shortage of voices in health care that want to undo this harm and put primary care’s Humpty Dumpty back together again. The federal government and various state governments have launched a host of medical payment reforms designed to promote primary care. So have small, state-based insurers and large corporate insurers, which are attempting to encourage value-based approaches. Some of these insurers have also begun to organize their own primary care groups, directly employing the primary care clinicians. Increasingly, large retail chains (such as CVS Health and Walgreens) have done the same in fits and starts. And private equity investors are organizing and buying primary care practices. All these interventions are based on both the rhetoric of primary care being foundational and the perception that, at present, much of primary care is failing. The proposals also share a common faith that we can move to a value-based health care system, which entails turning from fee-for-service to methods of prospective payment.
The goal of this book is to assess whether there has been real progress, and whether the primary care sector will do a better job of assisting patients with their health care journey, delivering value-based care, and producing a more efficient health care system. As noted, there is little research to this point on the evolution of primary care. The insightful blogger and commentator Kevin O’Leary recently revisited an article by Paul Keckley written in 2019, “Primary Care Is the Bridge to Health System Transformation: Who Will Build That Bridge?” Keckley had outlined the transition from small practice Primary Care 1.0, to hospital aggregation of Primary Care 2.0, to primary care practices designed to manage care, Primary Care 3.0. Keckley argued that building Primary Care 3.0 was motivated by the perception that spending more on primary care would reduce specialist and hospital spending, and thereby total spending. He also recognized that traditional Primary Care 1.0 and 2.0 could not justify additional capital investment; the savings on total cost of care were critical. At the center of Primary Care 3.0 was the well-resourced team of clinicians (nurses, doctors, advanced practice clinicians, pharmacists, and care coordinators) who anticipated patient needs and avoided costly episodes of care.
Keckley proposed that the potential investors in Primary Care 3.0 would likely be hospitals, insurers, private investors, and retail health. O’Leary, writing five years later, found that hospitals really had not contributed. He pointed out that insurers, investors, and retail health had all made sporadic progress, punctuated by well-publicized retreats. In summary, he concluded, “it doesn’t seem that any of the approaches have been consistently successful in investing in a new wave of Primary Care 3.0 that has disrupted the health care industry.” Indeed, the health services literature contains few reports of disruptive innovations.
Ironically, some argue that existing investments and investors have had the opposite effect, essentially expediting the demise of primary care. Note that most of the investors enumerated by Keckley (and O’Leary) are for-profit corporations. Many commentators, perhaps best represented by Professor Timothy Hoff, have argued that the weight of insurer, regulator, and corporate influences on primary care “produces a healthcare marketplace that comes across as increasingly impersonal and transactional; coldly calculating and corporate in its strategizing; and relying on half-baked policies and delivery ‘reforms’ that lack a true appreciation for the deep complexity of health care work.” According to this line of reasoning, the would-be “saviors” are corroding what is left of primary care. They are not producing team-based Primary Care 3.0 but destroying Primary Care 1.0.
In its emphasis on the human touch and the moral commitment to the patient, this argument is appealing. But it offers no way forward. No primary care policy expert believes the answer is a return to small-group and solo private practice. More importantly, the financial basis for a return to the past is not apparent. Value-based primary care offers the promise of a health care system that is not only higher quality and more equitable, but also more efficient, something all payers seek. Given the runaway costs of American health care, it would be a welcome improvement. Traditional fee-for-service billing of individual evaluation and management codes is what has morally and financially bankrupted primary care.
What can a qualitative review of a reasonable number of practices suggest about progress toward a value-based primary care? As noted above, there are good data on the degree of dissatisfaction with the status quo, Primary Care 1.0 and 2.0. And there is not much empirical evidence of a Primary Care 3.0−based disruption of health care. But value-based approaches to health care are taking seed in some areas, suggesting some promise for the future. Presuming that progress, the next natural question to ask is, what initiatives, which proponents of changes, and which investors in the largest sense of that word, are having real, even if small, impact? Given that we have few alternatives for reforming our health care system beyond trying to build a primary care base, those questions seem vital. The stakes are high for us as a country, as well as for every individual citizen and patient, and the solutions are of extreme importance. To uncover the progress, if any, of value-based primary care, I have spent much of the past three years talking to primary care clinicians and their administrative teams. Mine was an enriched sample, as I went first to primary care experts to identify examples of primary care teams that were focused on population health. I also used contacts in the insurance industry and in state governments to explore their initiatives. I tried to uncover not only each clinician’s self-assessment of their practice but also the financial incentives underlying their organization.
All along, I turn to the voices of the doctors, nurses, care managers, and behavioral health experts who have advised me over the past three years and described the reality they face daily. In that vein, I intend this book to be a report from the front line. Its title is illustrative. One cold December Monday, I was in Lynn, Massachusetts, visiting with doctors at the Lynn Community Health Center, a large, federally-qualified health center in the less-than-gracefully aging center of Lynn. All its patients were low-income, either on Medicaid or uninsured. One of the doctors I met was Elizabeth Quinn. She grew up in Quincy, Massachusetts, went to Harvard University, and then attended medical school at the University of Massachusetts. She trained in family medicine at the Lawrence Community Health Center and now specializes in obstetrics care for women with substance use disorders. In all of medicine, it is hard to imagine a more exquisitely difficult and subtle set of human interactions than those produced by this intersection of the strength of motherhood with the tragedy of addiction.
Yet Quinn seemed perfect for the job. Her language, particularly in the way she made certain points, was exceptionally keen and insightful. Just as impressively, she was so grateful for all the help she got from her colleagues, from the community health center, and from Salem Hospital. Her response to my question about how she would describe her practice was slow in coming, yet measured and thoughtful. After a long pause, she said, “Wonderful, crazy, broken.” Perfectly put. In this book I allow that yes, primary care is broken, and it is absurd that we have let this happen. Most primary clinicians are unhappy, and their practices are unable to fulfill all of their patients’ needs. But I do see signs that primary care is moving to a value-based foundation, one that is driven by the marvel of the interactions of dedicated primary care clinicians with their patients.
Troyen A. Brennan is a physician executive and author of Wonderful and Broken: The Complex Reality of Primary Care in the United States.
