The US healthcare system is an underperformer (highest healthcare spending for the lowest health system performance) compared to the other ten economically advantaged countries primarily due to differences in access, administrative inefficiency, disparities in healthcare delivery, and also due to the illogical underinvestment in primary care. Despite evidence by the Dartmouth Atlas of Health that the regions in which a higher percentage of Medicare beneficiaries receive majority of their care from a primary care physician lends to overall lower costs, higher quality of care, and lower rates of avoidable hospitalizations, the US continues to underinvest in primary care relative to other nations. Because of perverse incentives and overall fragmentation that is rampant in American healthcare, conscious and deliberate effort is needed to keep primary care at the forefront of clinical practice and population health improvement, including:
- Implementation of quality improvement practices that have a theoretical basis
According to Harvard Medical School’s Center for Primary Care established in 2011, there are five components necessary in improving primary care including evidence-based change concepts and tools, fostering strong relationships within and across practices, simple systems for reflection and feedback, structured time for team discussion and planning, and regular and meaningful engagement of leaders. The general theme is that quality improvement processes that have been validated (e.g. PDSA cycle) and implementation of driver diagrams that break up larger processes into smaller chunks/concepts have value and are worth the time to problem solve.
- Prioritizing patient-centered care
Care should be collaborative with patients’ preferences and values in the context of their socioeconomic conditions being respected. If there is less information asymmetry in clinical practice, then patients can be more active participants in their healthcare. Overall quality would improve with cost savings, as patient engagement research has demonstrated. Truly understanding a patient’s capacity and health literacy will improve a primary care physician’s ability to be effective in delivering patient-centric care.
- Payer reimbursement for provider innovation in preventive and multidisciplinary care
Primary care prioritization with the US healthcare system depends on heavy investment from payers because of the nature of reimbursement for clinicians’ time and services. In addition to a value-based compensation model that payers like Blue Cross Blue Shield reward providers with, more creative and interdisciplinary measures could be more payer driven. Humana’s Bold Goal program is a partnership between an influential payer and San Antonio Health Advisory board to partner with HEB grocery stores, community clinicians, and the YMCA to increase patients with diabetes’ better nutritional understanding of their choices. Because of the cost savings involved with more investment in primary care, it would make sense that payers would be incentivized towards this trend.
- Leveraging of non-clinical members of a team to deliver comprehensive, value-based care
Substantial evidence suggests that patients do not receive all of the preventive and chronic disease care that the U.S. Preventive Services Task Force advises on the basis of its best evidence because clinicians simply don’t have the time. Oak Street Health is a Chicago based network of value-based primary care centers that developed a clinical informatics specialist program 2014 where technical scribes were able to provide evidence-based recommendations and data support which resulted in improved effectiveness metrics, overall operational efficiency, and physician joy of practice.
Investment in primary care is necessary for the US healthcare system to have improved outcomes. Efforts at the community level, reinforced by theoretical models and financially backed by payers, are necessary in making changes that can yield significant population health improvements.