Neglect of Primary Care Infrastructure Continues
On Aug. 25, Kevin Grumbach, M.D., Thomas Bodenheimer, M.D., Deborah Cohen, Ph.D., Robert L. Phillips, M.D., Kurt C. Stange, M.D., Ph.D., and John M. Westfall, M.D., published a “Perspectives” article in The New England Journal of Medicine (NEJM) entitled, “Revitalizing the U.S. Primary Care Infrastructure.”
The authors begin the article by citing the COVID-19 pandemic and how there must not only be presidential leadership during a public health crisis, but also a dedicated team that reports to senior leaders and coordinates federal and state activities, uses a tight set of measures to assess progress, and is accountable for results.
“These elements are part of the Biden administration’s COVID-19 vaccination implementation program, which includes a task force charged with getting shots into arms. On this measure, the nearly 200 million vaccine doses administered in the United States by the end of May 2021 represented an important success,” the authors write.
That said, “These lessons can be applied to other critical health problems, including to the deficiencies contributing to decreasing life expectancy in the United States. Before the pandemic, the average life expectancy was already 3.4 years shorter in the United States than in other wealthy countries. One especially glaring problem is the country’s long-standing neglect of primary care.”
The topic of neglecting primary care in the U.S. is not a new one. In 2019, the American Academy of Family Physicians (AAFP) published an “In the Trenches” blog by Stephanie Quinn, AAFP senior vice president of advocacy, practice advancement and policy, titled “Why Do We Neglect Our Health System's Foundation?” Quinn believes that our current system has become entrenched in the “hero mentality” forgetting the role of the “helper.” Essentially, the boom of innovations in diagnostic testing, pharmaceutical and biologic treatments, new surgical techniques, etc. created a revenue-centered system, not a patient-centered one.
Quinn writes that “The problem is that to finance these heroic interventions, we drain resources from the healthcare interventions and physician services that offer the best opportunity to prevent disease, maintain health, and promote longitudinal health across a majority of a lifespan.”
Not only are primary care practices neglected, but practices are also in danger of closing due to declines in revenue and staff. David Raths, Contributing Editor for Healthcare Innovation, reported on a survey in April 2020, that primary care practices were in jeopardy.
Raths writes that “The survey suggests that many primary care practices are at serious risk of shuttering. Forty-two percent report concerns about layoffs and furloughed staff, and an overwhelming majority (85 percent) have seen dramatic decreases in patient volume.”
According to a July 2019 article from The Lancet, titled “Prioritizing primary care in the USA,” on July 17, 2019, the Patient-Centered Primary Care Collaborative (PCPCC) issued the first report to look at primary care spending by state, including spending from across different types of payers.
The Lancet states that “The report did not find substantial regional patterns but shows that primary care use is unevenly distributed across age, with care for children younger than five years accounting for 26 percent of primary care spending according to the narrow definition [the narrow definition of primary care in the PCPCC report included categories like general practitioners, internal medicine, and pediatrics]. The report also found an association between increased primary care spending and fewer emergency department visits and hospital admissions.”
Further, The Lancet reports that the PCPCC report only gave a glimpse of primary care spending and at a time state-level policy makers have been looking to shift healthcare back to a more primary care-focused approach. The report also states that there is a need for a more standard definition of primary care to better standardize progress across programs. Individuals’ access to primary care is directly related to lowering healthcare costs, but in the U.S., patients are often waiting for care until costs—physical and financial—are much greater than they need to be.
The authors for NEJM continue “A recent report from the National Academies of Sciences, Engineering, and Medicine (NASEM), Implementing High-Quality Primary Care, recognized a well-functioning primary care system as a common good and outlined an implementation plan for supporting U.S. primary care. (One of us was a cochair of the report committee and another was a consultant.) Two important elements of the proposed plan involve establishing a Department of Health and Human Services (HHS) Secretary’s Council on Primary Care and creating a scorecard to track progress in boosting state and national primary care infrastructure. These recommendations mirror essential components of the federal government’s vaccination implementation strategy.”
The authors explain that the neglect of primary care, including current payment systems, could be addressed by implementing a government entity that is responsible for defining and overseeing a coordinated national primary care strategy. The current federal government’s approach is disjointed and other agencies who play a role in primary care don’t have well-coordinated efforts. There is no HHS team specifically dedicated to rebuilding primary care and ensuring that the system is running smoothly.
The authors conclude that “Creating a council on primary care wouldn’t be sufficient to solve the problem of poorly supported primary care, but without such a concerted effort, the most important infrastructure available for advancing health equity will continue to erode. If a council focused on primary care had existed during the height of the Covid-19 pandemic in the United States, it could have helped rapidly mobilize primary care to address vaccine equity and shore up public health, particularly in rural and historically marginalized urban communities. Moving forward, we believe an infrastructure investment plan should include oversight, tools, and resources for rebuilding primary care, with clear accountability vested in a single council and an overarching goal of achieving health equity.”
