Primary Care in Critical Condition

For decades there have been lamentations in the United States about the sorry state of primary care, traditionally a patient’s first and most consistent contact with the healthcare system. “Are there enough primary care doctors?” asked the National Academy of Medicine’s (then called the Institute of Medicine) Committee on the Future of Primary Care in 1996. “Are they merely gatekeepers? Is the traditional relationship between patient and doctor outmoded?”

Since then, the alarm bells ringing in those questions have only grown louder. In 2006 the American College of Physicians (ACP) declared that primary care, “the backbone of the nation’s healthcare system, is at grave risk of collapse.” That year, in a landmark New England Journal of Medicine article, Thomas Bodenheimer, M.D., M.P.H., a professor at the University of California, San Francisco (UCSF) and founding director of its Center for Excellence in Primary Care, identified “a confluence of factors that could spell disaster.” Patients are increasingly dissatisfied with their care, he wrote, and primary care physicians are unhappy with their jobs. “The quality of care is uneven; reimbursement is inadequate; and fewer and fewer U.S. medical students are choosing to enter the field,” says the Bodenheimer jeremiad.

Indeed, the field seemed stuck in a vicious cycle. Physicians suffering from burnout and deserting primary care left their remaining colleagues with larger panel sizes, increasing dissatisfaction on all sides. Payers remained stingy with reimbursement. Graduating medical students shunned primary care in droves for more lucrative specialties. ACP figures cited by Bodenheimer showed that between 1997 and 2005 the number of U.S. students entering family practice residencies dropped by half.

The demand side also looked rather bleak. From 2008 to 2016, visits to primary care physicians (PCPs) fell by 6% to 25% in five sets of survey data representing commercial, Medicare and nationally representative samples. A 2021 study attributed the declines to “fewer contacts per patient.” Perhaps that’s no surprise, given the profusion of walk-in urgent-care clinics, telehealth services and quick-care drugstore clinics. Patients had been voting with their feet against primary care docs even before the pandemic kept millions at home and telehealth took off.

Yet primary care “remains the foundation upon which a high-performance, cost-effective health care system must be built,” insists the Purchaser Business Group on Health, an employer group that focuses on healthcare costs and quality. The purchaser group says healthcare costs are 33% lower for U.S. adults who regularly visit a PCP and their chances of dying prematurely are 19% lower than those who rely on specialists alone.

Other countries seem to get it even if the U.S. doesn’t. Study after study has shown that other wealthy countries outperform the U.S. on almost any healthcare metric you might imagine while devoting a far smaller share of their gross domestic product to healthcare. One explanation: They put more emphasis on primary care. When a 2020 Commonwealth Fund survey asked in 11 advanced Western nations how many people had a regular doctor “or place to go for care,” only Sweden ranked behind the U.S. When the question was how many had a primary care provider relationship of five years’ standing or more, Sweden slipped ahead, leaving the U.S. dead last.

There’s also trouble among those providing the care. “We have a real workforce crisis,” Bodenheimer warned in 2017. Asked by Managed Healthcare Executive® in a recent interview whether this situation had improved or deteriorated in the years since, Bodenheimer replied: “Let’s just say it’s still bad.” Like others, he’s been preaching the gospel of team-based care: physician assistants, nurse practitioners, medical assistants and others working in concert with PCPs and, to some extent, taking on the tasks and responsibilities that used to belong only to those with M.D. or D.O. next to their names.

SHARE THE CARE

But even Bodenheimer says teams aren’t the full answer, noting that the total number of all primary care providers who can bill for their services, be they doctors or not, is slowly going down as a percentage of the population.

Primary care delivery, in some places and by some groups, has become more efficient. There’s an analogy to climate change — Bodenheimer didn’t volunteer it, but when it was offered, he embraced it. “You do a little bit for climate change,” he said, “but the climate’s getting worse much faster than what we’re doing to help it, and it’s sort of a similar thing with primary care.”

That’s not to say Bodenheimer is all doom and gloom. He’s been a hopeful evangelist for team-based care for at least 15 years. And there really should be two teams in primary care, he explains: the core teams consisting of clinicians and their medical and other kinds of assistants and the interprofessional teams that include physicians collaborating with other professionals — pharmacists, physical therapists and social workers as well as nurse practitioners and physician assistants.

With an extra medical assistant on the core team working as a scribe, says Bodenheimer, physicians can see more patients because they’re relieved of many of the documentation tasks that overwhelm their days and that they often take home to work on after a long workday is over. The nonphysician members of interprofessional teams, he says, can save physicians even more time by seeing some patients themselves “if you let them do what they’re capable of doing,” he says. Some studies have shown that pharmacists can do a better job of taking care of people with diabetes than physicians and that physical therapists can do the same for people with musculoskeletal problems, says Bodenheimer.

Team-based care can be seen as an unavoidable adaptation to mounting pressures, a positive change or both. One booster of the team approach is Megan Mahoney, M.D., MBA, who recently left Stanford and is now chair of UCSF’s Department of Family and Community Medicine and a colleague of Bodenheimer’s (she calls him “the father of all of us.”). The old approach of every patient seeing a doctor for every visit has become unaffordable, says Mahoney — and isn’t necessary for quality care.

“There will be an important role for a primary care provider as the captain of care, coordinating the care, but I’m not sure that needs to be a physician,” she says. In Mahoney’s view, doctors can focus on assessment and diagnosis and then delegate much of the rest of the medical encounter — treatment advice, the details of care coordination — to other team members.

Although economics is forcing the change to this team approach, we shouldn’t regret it because it holds some advantages, says Mahoney. There are pluses, for instance, in having multiple clinical minds thinking about a patient, she says. “For a medically complex patient,” says Mahoney, “a team can get together on a regular basis and talk about all aspects of the care of that individual, from food security and social determinants of health to access to community resources, in addition to diet, exercise, and medical care.” True, the character of the patient-physician relationship may change, but Mahoney says that trust in providers can be transferred and distributed. Doctors can introduce other team members to patients as those they trust and referencing the team members’ area of expertise and potential benefits to the patient. “When people hear that,” says Mahoney, “they feel reassured.”

There’s still a lot to figure out, she says. And there’s also the obstacle of the way U.S. healthcare is paid for, notwithstanding the armada of value-based care models and programs that has been launched the past several years, says Mahoney: “The biggest barrier currently is the way (much) primary care is funded — by a fee-for-service model, which is contrary to what primary care is all about. It’s about prevention, not utilization of services.”

Sometimes physicians themselves are a barrier. As Bodenheimer remarked in a 2017 video interview: “Physicians are kind of crazy, in a way. On the one hand (they say), ‘I can’t do all this work; there’s too much work; I can’t stand it any longer.’ Well, you have this wonderful RN. Evidence shows that she could probably take care of half of your patients with diabetes without taking any of your time.” Here on the video he gestures frantically with both open hands, imitating the physician. “ ‘Oh, no, no, no! Can’t do that. Has to be me!’ ” Research, Bodenheimer continues, shows that nurses, pharmacists, behaviorists and physical therapists can in many cases take over some of a doctor’s workload with no compromise in quality. “Doctors have to learn how to share the care,” Bodenheimer says in the video.

Asked about this issue of the doctor’s ego, Randolph Gordon, M.D., M.P.H., is ready with an answer. “If one’s ego satisfaction is power in being an authoritarian ruler,” he says, then yes, there’s “ego diminution” when team-based care takes effect. “But,” he says, “if one enjoys working with other people, leading and learning from team members to provide better care and see better outcomes, then in my mind that’s ego enhancement.”

Teams and tech

Gordon is managing director at Deloitte Consulting, which issued a report on the physician of the future two years ago based on interviews with 13 thought leaders and 680 physicians done just before the pandemic. Unlike Bodenheimer, Mahoney and many others, Gordon rejects the label “crisis” for the state of primary care. He prefers a milder, business-speak characterization: “a time of transformation.”

Gordon sees “a lot of hope on the horizon for practicing primary care,” and embraces a vision that “returns the joy of practicing medicine to physicians.” But his firm’s forecast of what PCP life will be like 10 years from now — based on those interviews — suggests that such hope and joy will need to stand up against some pretty drastic change.

“We envision a future where medicine will be a team sport, with humans and machines working together, and consumers playing an important role,” says the Deloitte report, conjuring a future “marked by technological breakthroughs in robotics, AI, nanotechnology, quantum computing, fifth-generation wireless technologies, 3D printing and material science.” In this dizzying new world, PCPs aided by tech will be sharing more of their work with physician assistants, nurse practitioners, medical assistants and others. Physician survey respondents (not just PCPs) estimated that 30% of their current work could be performed by nonphysicians and 18% could be automated.

The doctor’s role is already changing, and Deloitte’s survey predicts that it will change a lot more, quickly. “What we learned in medical school was memorizing — signs and symptoms, differential diagnoses and treatments,” says Gordon. “But as fast as medical knowledge is expanding, one individual cannot put all of that data into her brain. So the role needs to change from trying to memorize all the data and apply that to an individual’s health situation to coordinating the data and the care. And, if you’re my patient, I can coach you.”

But before PCPs breathe too big a sigh of relief over the arrival of the cavalry in the form of teams and tech, they should check out the long list of areas the Deloitte report says PCPs will need to master and understand: empathy, cultural sensitivity and storytelling, so they can relate better to both colleagues and patients; leadership skills; data handling, genetic information and how to interpret it; the economics of medicine; and the “direct and indirect costs from the perspective of the organization, the patient, and the healthcare system.” The daunting list went on.

And, oh, new kinds of specialization may be coming, too. “Future PCPs,” says the report, “may specialize in the types of patient populations they serve rather than in body systems: the young and healthy, adolescents, the elderly, patients with complex conditions, or those in specific communities.”

The upshot? “We need people in medicine who are really good at being human,” says Gordon.

New training

It’s conceivable that new personality types will be attracted to primary care as it is redefined in coming years: tech-savvy young people, more favorably disposed to collaboration than to being the-doctor-knows-best authority figures.” I will postulate they’re not necessarily different people,” says Sterling Ransone, M.D., outgoing president of the American Academy of Family Physicians (AAFP). But they will almost certainly be educated and trained in a different way, in his view. They’ll be more adept at incorporating new tech tools into what they do. One example: “Right now,” says Ransone, “there’s technology I can hold up to a patient’s eye to take a photograph that can be downloaded into an AI (artificial intelligence) platform that will diagnose diabetic retinopathy with the accuracy of a fellowship-trained retinologist.” Lisa Howley, Ph.D., president of the Association of American Medical Colleges (AAMC), says curriculums are changing, so today’s med students are learning about data management, AI and “how to work within a very high-tech environment.”

And if technology is on the syllabus, so are teams. In 2009 the AAMC and five other groups became founding members of the Interprofessional Education Collaborative, which seeks “to help prepare future health professionals for enhanced team-based care of patients and improved population health outcomes.” (Today there are 21 member groups.) “We’ve actually made quite a bit of progress in understanding the new science of teaming,” says Howley, but “we still have a long way to go.”

Howley agrees that a higher proportion of medical school graduates should be choosing primary care disciplines. In the 2022 National Resident Matching Program, her academy reports, just 15.7% of the positions filled were in primary care.

Bodenheimer says a primary care program at the University of Colorado is a model of effectiveness that can and should be replicated. There are two medical assistants for every primary care physician. One takes a patient’s history before a clinician comes into the room, and the other serves as a scribe. The approach reduces physician burnout from 50% to 20%, says Bodenheimer.

The long view

Why don’t more primary care practices emulate the Colorado approach? Bodenheimer ticks off three reasons: physicians’ lack of trust that medical assistants can perform all the tasks assigned to them; state laws and regulations that don’t permit nurses and pharmacists to get paid for some of the things they can easily do for patients; and shortsighted chief financial officers (CFOs) who insist that revenues must exceed expenditures every month. Those CFOs should take a longer-term view, he says. The Colorado-style team approach lets physicians “see an extra patient or two a day, and under fee-for-service that’s enough to pay for an extra medical assistant. They can increase market share, and actually make more money in the long run.” Also, “when burnout goes down, fewer physicians leave the practice,” he says. “And we know it takes something like $1 million to hire a new physician to take the place of someone who’s left, and then your productivity’s going to be down for quite a while.”

Also shortsighted, in Bodenheimer’s opinion, is the AAFP’s opposition to independent prescribing authority for nurse practitioners. “It’s the craziest thing I’ve ever seen,” he says. “They feel nurse practitioners are competing with them, but they desperately need nurse practitioners to help them take care of these huge panels.”

Nevertheless, there has been some good news for primary care. Medicare’s system of relative value units has been adjusted to “redistribute payments from procedural to non-procedural physician services in a meaningful way,” as John D. Goodson and co-authors reported in Health Affairs in 2021. For both specialists and PCPs, CMS has changed coding for levels of office visits to more accurately reflect medical decision-making.

However, recent innovations such as the accountable care organization (ACOs) and the patient-centered medical home (PCMH) have failed to transform primary care as many had envisioned (although ACOs have plenty of proponents and some positive results to brag about).

PCMHs, in particular, get low marks from Bodenheimer: “They’ve been pretty much a flop.” The patient panels were too big, the doctors too busy and the practices didn’t have the enough money to create a strong team, he says. “You can get recognition to be a PCMH all you want, and nothing changes.”

Of course, it’s entirely possible that things will change — that enough good efforts in enough places at the right time will cause a new, self-perpetuating virtuous cycle that spins in the opposite direction from vicious one that has been the driving force in U.S. primary care. Bodenheimer notes that annual U.S. healthcare expenditures totaled more than
$4 trillion in 2020, with just 5% of that spending going to primary care compared with 12% in European countries. “Primary care really should get 10% of the healthcare dollar rather than 5%,” he says. “If we do that, we’ll have enough money to hire the people — the nurses and pharmacists and physical therapists, for example — to be on teams that can help the physicians take care of their overly large panels and make life a lot better for the physician. And that would attract more medical students to go into primary care and could reverse the whole downward trend.”

So there it is. Just move $200 billion around, and you’ll get many more physicians eager to embrace what is arguably U.S. healthcare’s most crucial, most problematic — and potentially most rewarding — challenge.

Timothy Kelley is a healthcare journalist in New York City.