Primary Health is . . . a Common Good

This blog has been inspired by the landmark report of the National Academy of Engineering, Science, and Medicine‘s Consensus Study Report  on Implementing High Quality Primary Care (“IHQPC”). References are to specific pages within the document.

“Primary Care in the United States is slowly dying.” 

Wow. 

So begins the 427-page tour de force from the NAESM on what is required to fundamentally “reframe” and most importantly “implement” high quality Primary Care in our country. The study defines high quality Primary Care as “the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams that are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities” (IHQPC, pg 46 )  I think it’s easy to agree that in the U.S. today, this definition remains aspirational, but not unattainable, and if implemented would create a foundation from which our nation’s health could be secured. 

So if attainable, why is foundational Primary Care crumbling? For starters, the specialty has been systematically asphyxiated by fee for service payment models and malnourished, underfunded, and unappreciated for decades. This has resulted in a further misallocation of capital which inadvertently promoted a hyper-specialized, procedurally-focused, and excessively costly specialty service orientation that does not serve any common, coordinated, nor comprehensive health aims.  

“The U.S. system is in crisis and being eroded by many forces, including inadequate investment in and chronic under-resourcing of services; incompatible payment models; diminished trainee interest; increased opportunity for subspecialty training; the challenges of rural access; the decreasing scope or comprehensiveness of primary care in many settings; and the lack of integration with health systems, community-based services, and public health” (Basu et al., 2019; Casalino et al., 2014; Chen et al., 2013; Christakis et al., 2001; Coker et al., 2013; Cooley et al., 2009; Coutinho et al., 2019; IOM, 2012a; Liaw et al., 2016; Long et al., 2012; MedPAC, 2014; Mostashari, 2016; Phillips et al., 2009) (IHQPC, pg 22).

The stone cold facts of the “chronic underinvestment” in Primary Care according to the IHQPC report are generally familiar but nonetheless disturbing: 

• While more than 55% of all health care visits are to primary care physicians (Johansen et al., 2016), primary care only receives ~5% of all health care spending (Martin et al., 2020)
• The U.S. primary care physician workforce had declined by 5.2 physicians per 100,000 population overall between 2005 and 2015 resulting in a loss of 85 lives per day overall (this is equivalent of a 200-person airplane crashing every 2–3 days (see Appendix C for the committee’s calculations). 
• U.S. investment has fallen short of that needed to make high-quality primary care accessible throughout the nation (Martin et al., 2020; Reiff et al., 2019). 
• Fewer people are going to a primary care office than a decade ago falling 6-25% depending on the source (Ganguli et al., 2019, 2020) and problem-based visits dropping 24 percent during the same period.
• The COVID-19 pandemic amplified pervasive and perverse economic, mental health, and social health disparities (Dorn et al., 2020; Smith, 2020) that could have been alleviated if high-quality primary care were ubiquitous nationwide (Baillieu et al., 2019; Basu et al., 2016, 2017; Koller and Khullar, 2017; MedPAC, 2008). 
• The pandemic shock also showed how brittle our national Primary Care foundation was and the existing payment models have pushed the specialty to a brink of insolvency. 42% of respondents laid off or furlough staff and 51% were uncertain about their financial viability (The Larry A. Green Center and PCC, 2020).

The resulting reality is a disjointed health care enterprise that misallocates resources between primary and specialty care, burns out clinicians, generates financial pressure on primary care practices, limits the relationships that clinicians and patients can develop, produces suboptimal care, creates health disparities and inequities, is causing the US to fall behind the rest of the developed world in population health outcomes, and is creates regressive trends in the otherwise remarkable mortality gains of the past 100 years (NRC and IOM, 2013). 

Yikes! 

Unfortunately, we have been hearing about these issues since the 1996 IOM report on Defining Primary Care. But, what I love about this new consensus study is that it is intended to be an implementation plan. And, to begin discussing implementation requires reframing the debate about what Primary Care actually IS and what assuring its place and foundation actually MEANS: 

“Primary Care remains the largest platform for continuous, person-centered, relationship-based care that considers the needs and preferences of individuals, families, and communities and whose value is demonstrated with markedly stable usage patterns for more than 50 years (Green et al., 2001; Johansen et al., 2016; White et al, 1961). 

The authors point out that high-quality Primary Care has been proven, time and time again, to be the most effective avenue for helping people get healthy and stay well while also effectively managing the ever-escalating costs of care. It is also the one specialty that can address the structural social issues behind our nation’s increasingly poor health as well as poor record on health disparities and social inequity. In fact, because of its “demonstrated and superior capacity among health care services to improve population health and health equity for all society”  it should not be viewed as another “commodity service whose value need to be demonstrated in a competitive marketplace but rather as a Common Good to be promoted by responsible public policy and supported by private sector action” (IHQPC, pg 373).

The designation as a “Common Good” is something that I have not considered in this context before–and it comes with both some nuance and many implications. From a nuance perspective, there is a difference between a Public Good (which can be consumed by all but is not diminished when more people use it) and a Common Good (which can be depleted if overused and may disappear absent regulation). The economic definition of a Common Good further describes it as a good or service that is both rivalrous (the services are limited, so more for one person means less for another) and non-excludable (users cannot be prevented from accessing it regardless of whether they have paid). The implications of this are both societal and moral. While the national debate about health care as a human right remains highly contentious, supporting foundational Primary Care as a part of our basic social contract seems to have widespread consensus given it “is the only component of health care where an increase in supply is associated with better population health and more equitable outcomes”  (IHQPC, pg 48-49).  High Quality Primary Care is too important a cause to be left so emaciated and its relevance requires it not be relegated to emeritus status either. This further supports that Primary Health should be “particularly prioritized among health care services as a Common Good because of both its societal value and its precarious status.” (IHQPC, pg 48-49).  

It’s also the reason we feel such urgency in our work at Crossover Health. The IHQPC report is damning for sure, but damn it, we all need to fix this–for our members, our providers, our communities and our country as well. The road to doing the right thing the right way can often seem both “long and lonely”, but there are great examples of what is possible when Primary Care is done right (shout out to my fellow innovators at ChenMed, CityBlock, Oak Street, Devoted, Aledade, and others who haven’t succumbed to nor been seduced by the “cheap and easy” short term fixes). Crossover is already contributing to this critical Common Good, and adding our testimony to the growing chorus of those who want to practice, support and experience “health as it should be.” 

Crossover will always remain committed to innovating the way forward by demonstrating both why and how Primary Care can and should become a pervasive Common Good.