The U.S. Department of Health and Human Services (DHHS) initiative to strengthen primary health care, launched in September 2021, aims to establish a federal foundation that supports advancement toward a goal state of the practice of primary health care.
In its final state, the practice of primary health care:
- Supports health and well-being through sustained partnerships with patients, families/caregivers and their communities;
- Fairly provides first contact access to all, as well as full care of the person, over time, by interprofessional teams; and
- Coordinates and integrates care across all systems, including other health care providers, public health, and community health promotion and social service organizations.
To strengthen primary health care, it is essential to build trust between providers and recipients of care. Establishing and strengthening trust depends on the depth and duration of the interpersonal relationships created. Therapeutic relationships are based on a thorough and shared understanding of the factors in a patient’s life circumstances that contribute to health problems and agreement on potential interventions and solutions to address these problems.
This approach will only be truly successful if it is enabled through multiple approaches in today’s healthcare culture. According to the World Organization of Family Physicians, the goal of effective family practice, and therefore of effective primary care, “is to promote personal, comprehensive and continuing care for the individual within the context of the family and from the community “.
Successful and equitable access to primary health care across cultural, ethnic and socio-demographic characteristics requires a strong primary health care workforce. According to 2020 data, approximately 22% of clinicians in the United States choose a career in primary care.
The American Medical Association has also found that “graduates of osteopathic schools disproportionately help fill the void in primary care.” According to the Canadian Medical Association, 52% of physicians practice primary care. In Europe, many countries have well over 50% general practitioners per 100,000 population, in some cases exceeding 70%, compared to 42% in the United States. Our Canadian neighbors and Western European allies outperform us in most if not all measures of health care. quality and lifespan.
They actively practiced what we have continued to play down – that a variety of social, economic, and political factors account for the relatively low life expectancy at birth in the United States. These include the lack of universal health care, a poorly functioning public health system, insufficient federal drug oversight, and unhealthy lifestyles that contribute to chronic disease. Promoting a strong primary care workforce absolutely requires widespread mentorship and role modeling by practicing primary care physicians.
Nearly 75% of primary care physicians—new graduates and those already established—now practice under an employment arrangement within a hospital/health care system. The era of the independent primary care clinician is rapidly disappearing, mainly due to heavy administrative burdens and the insurance system.
They are subject to wRVU quotas (The acronym wRVU refers to Relative Labor Value Units. Here’s how it works: For each patient exam or procedure performed, a clinician receives a number of working UVRs. These wRVUs are then multiplied by a conversion factor, which is a specific dollar amount. This largely determines what a clinician earns. Many Quality Metric income incentives (percentage completion goals in the areas of cancer screening, vaccinations, well visits, and management of chronic conditions like diabetes require special attention). They are important, but when pushed too hard by health systems that derive revenue from “achieving pre-determined benchmarks” they compete with essential medical student modelling/mentoring roles. skills needed (i.e. active listening) to build deep and lasting relationships with patients .
HHS must formalize an “educational” RVU system and payment mechanisms that, among other things, encourage and support mentoring/role modeling for undergraduate medical students in primary care.
Newly graduated medical residents choosing to practice primary care have increasingly siloed their practices. In much of the country, broad-scope practices where primary care clinicians provide outpatient, inpatient, and home care are over.
The “SNF’ists, Intensivists and hospitalists” are now ubiquitous. This severely limits the clinician’s ability to truly “know” their patient. It has been proposed and often validated that 40-50% of individual patient behaviors (diet, exercise level, smoking, etc.) contribute directly to health outcomes and 20% are attributable to the patient’s social and physical environment. the individual.
The social determinants of health (SDoH) are the conditions in the environments where people are born, live, learn, work, play, worship and age that affect a wide range of health outcomes and risks, functioning and quality of life. SDoH data networks such as “Aunt Bertha” and organizations such as “Unite Us” are important, provide crucial links to local SDoH resources, and should be shared across the world of healthcare providers and allied health professionals. at all levels.
But we can do even more. We now have over 80 ICD-10 (International Classification of Diseases) diagnostic codes that address SDoH. Documentation of these codes directly supports expanded recognition of a patient’s social/behavioral/environmental interaction and active recognition of the time required to treat this relationship rightly improves primary health care billing in our paid medical system. in action – but we can do more. The goal should be to screen for SDoH needs, connect individuals to needed services, close the communication loop, and track clinical and medical service utilization outcomes.
Community health workers are lay members of the community who work with the local health care system in both urban and rural settings. They typically share ethnicity, language, culture, socioeconomic status, and life experiences with members of the community they serve. Community health workers can also partner with community members to target specific social determinants. These workers can support other members of the community when they hold public meetings to educate their peers or work with policy makers to implement the changes needed to improve health and well-being.
HHS should formally recognize and support the growth of a community health worker workforce to embrace the value of addressing the social determinants of health as central to health care delivery and health care outcomes.
Health Information Exchange (HIE) is essential to providing coordinated care to our patients.
Additionally, as primary care providers of all “bands” – doctors, APRNs, AMs, LCSWs, administrative staff, etc. – we need to help our patients navigate the extremely complex web of health care “systems” that make up American health care culture. It requires team care.
Accountable care organizations within health systems were designed to provide this integrated service. The success of team-based care is unclear, it varies widely by healthcare organization. HIE is also variable. This has been very unsuccessful in states where many health systems and electronic health records exist, NONE of which actually shares data. This makes it nearly impossible to coordinate clinical care and deliver “high value” care to our patients – redundant care and alleged gaps in care are prevalent. This is unacceptable.
Unfortunately, a volume- and revenue-driven healthcare system competes with paradigm-shifting initiatives. Population health data now makes it possible to reach patients on a scale never imagined or achieved before. We can now apply the health quality measures of the National Committee on Quality Assurance (an independent, non-profit organization in the United States to improve the quality of health care) to a greater percentage of the population whose care is attributable to our clinical practices.
The goal, however, should not be driven by potential increases in compensation earned when target metrics are achieved, but rather by improving the health of our attributable patient populations. And we MUST NOT degrade the individual patient-clinician relationship by “focusing too much” on population measurements.
HHS has the biggest challenge here: changing the landscape of health care funding, prioritizing care coordination and cost-effective use of resources that do NOT emphasize shareholder value and “return”. on investment” (ROI).
Finally, technological innovation cannot be ignored. Web-enabled devices such as smartwatches, blood pressure cuffs, and web-enabled glucose meters that transmit data to healthcare providers, continuous blood glucose monitors that give patients more ownership and control over the management of their disease and participation in the patient portal should be encouraged and supported.
Audio and audio-video remote clinical encounters facilitate sustained patient-provider communication, as do “online consultations” (a mechanism that allows primary care providers to obtain expert feedback on care and treatment of a patient without the need for a visit.These “remote” encounters enable up-to-date clinical care in rural and remote areas.The deployment of all these clinical support systems strengthens the clinical communication network and the relationships essential to improving the health of the general public.
HHS must support a robust web-based health care system that values remote health care technology as much as face-to-face encounters.
The time is NOW and it is high time to take the lead, put our “boots on the ground” and make these and other essential changes to support the health of our population.
Howard A. Selinger MD is chair of the Department of Family Medicine at the Frank H. Netter MD School of Medicine at Quinnipiac University. He is also a faculty member of the ECHN Family Medicine Residency in Manchester.