|Home | About | Journals | Submit | Contact Us | Français|
The United States has the most expensive, technologically advanced, and sub-specialized healthcare system in the world, yet it has worse population health status than any other high-income country. Rising healthcare costs, high rates of waste, the continued trend towards chronic non-communicable disease, and the growth of new market entrants that compete with primary care services have set the stage for fundamental change in all of healthcare, driven by a revolution in primary care. We believe that the coming primary care revolution ought to be guided by the following design principles: 1) Payment must adequately support primary care and reward value, including non-visit-based care. 2) Relationships will serve as the bedrock of value in primary care, and will increasingly be fostered by teams, improved clinical operations, and technology, with patients and non-physicians assuming an ever-increasing role in most aspects of healthcare. 3) Generalist physicians will increasingly focus on high-acuity and high-complexity presentations, and primary care teams will increasingly manage conditions that specialists managed in the past. 4) Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services. Design based on these principles should lead to higher-value healthcare, but will require new approaches to workforce training.
Primary care has been described as “integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”1 This and other seminal definitions of primary care do not specify a type of clinician, but rather refer to the set of essential functions which primary care serves within healthcare systems—namely, access, continuity, comprehensiveness, and coordination.1 – 3
Legislative reform, technological evolution, shifting public expectations, and pressure for cost discipline have set the stage for accelerating change for healthcare systems. Primary care requires a compelling vision and profound changes to thrive. We argue that primary care serves critical functions that will be as vital in the future as they have been in the past, and that these functions may be more optimally achieved through different configurations of people and technology, guided by four principles.
The major frameworks4 – 6 that conceptualize healthcare systems converge on the idea that healthcare systems should produce better health outcomes and patient experience at a sustainable cost. The World Health Organization’s framework additionally embraces equity as a primary aim of health systems by including the goals of financial and social risk protection and the fair distribution of health outcomes across populations. While all of the world’s healthcare systems struggle to achieve these aims, and experience different tradeoffs between healthcare cost, quality, access, and equity, the United States has the most expensive, technologically advanced, and sub-specialized healthcare, with worse population health outcomes and measures of equity7 than any other high-income country.8
Acknowledging the predominant role of factors outside healthcare in determining the health of individuals and populations,2 – 9 there is also convincing evidence that geographic areas with a higher concentration of primary care providers demonstrate better health outcomes, better healthcare quality, lower total medical expenditures, and more equitable health outcomes.3 The primary care functions of access, continuity, comprehensiveness, and coordination are each associated with improved care processes and outcomes (Table 1). As non-physician health workers can serve many aspects of primary care functions, including diagnosis and management, with equal or greater reliability and at lower cost, working as a team may create the highest value. Consistent evidence suggests that nurse practitioners and physician assistants perform many of the clinical roles in primary care as reliably as physicians, including the care of relatively complex patients.10 – 12 Care managers (typically nurses), community health workers, and patient navigators can prevent emergency room visits and hospitalizations as they work with primary care teams to coordinate and optimize health service utilization13; they may also help ensure patient adherence to medical regimens and reduce disparities in care by helping patients to overcome barriers, such as lack of transportation, low English literacy, or difficulty accessing social services.14
New models of care delivery, supported by legislative reform, reinforce the potential for primary care-based approaches to improve value. The patient-centered medical home (PCMH) is a construct for team-based primary care oriented towards improving the health of a panel of patients. Although outcomes vary, PCMH demonstration projects have shown promising reductions in costs and improvements in quality, attributable in part to effective teamwork.15 Early evidence regarding accountable care organizations indicates that those built around primary care, and therefore better positioned to negotiate a reduction in the costs of specialty and hospital services, fare better than those built around hospitals.16
In the U.S., prior to the quite recent preliminary changes in the direction of paying for value, healthcare financing has focused almost exclusively on payment for transactional, procedural care. Some have argued that the relative value unit (RVU) schedule for primary care visits and other cognitive activities undervalues the role of primary care and the skills and experience required of primary care practitioners and teams.17 – 19 Marginal finances and other external constraints, as well as internal limitations of primary care practices, result in challenging work–life balance, high rates of physician and staff burnout, workforce shortages, poor quality of care, and lower salaries and prestige compared to other specialties. Not surprisingly, given the low revenue streams and high expectations for unreimbursed labor, many primary care practices struggle to maintain financial sustainability.20 Practices that are succeeding financially are often doing so as a result of investment by a health system that values the patients cared for within the practice, but most of these systems are still paying for primary care services using the Medicare RVU schedule, leaving few options for practices to add high-value services that are not currently reimbursed. Some experts anticipate a sizable primary care workforce shortage,21 while others suggest that this shortfall could be moderated by changes in staffing models to accommodate greater provision of primary care by advance practice practitioners.22 However, nurse practitioner and physician assistant trainees face the same disincentive to choose primary care as do medical students.23
The forces creating pressure for change in healthcare systems are likely to increase. Most importantly, healthcare expenditures will continue to grow, and may again outpace overall economic growth, due to reinvigorated biomedical technological innovation, an increasing number of Americans receiving health insurance, the epidemic of chronic disease, which accounts for 86% of overall expenditure,24 and the growing proportion of Americans over the age of 65. There is also evidence of rising consumerism, whereby Americans increasingly expect a level of service from healthcare commensurate with other products and services and, at least for basic, acute care, value convenience over the reputation and expertise of providers.25 , 26
In the crucible created by forces for change, along with the unparalleled opportunity provided by the free enterprise system, it is not surprising that there are growing threats to traditional healthcare provision by new market entrants. Established market incumbents (such as pharmacy chains) as well as startups see the rampant waste of up to 40%,27 healthcare’s unparalleled lack of growth in labor productivity,28 the poor consumer-friendliness of incumbent healthcare providers, and the potential applicability of advances such as artificial intelligence as a business opportunity. The emergence of urgent care in retail pharmacies and standalone chains is an early example of how new business lines are beginning to infringe on aspects of care that have traditionally been the purview of primary care practices.26 Several telemedicine companies offering urgent transactional care over secure virtual platforms have also entered the market. While uptake of these telemedicine services has been relatively limited, they reflect the reality that, as long as traditional primary care practices fail to adequately meet patients’ expectations and needs, new market entrants will attempt to fill this void.
Some have suggested a future for healthcare wherein the majority of highly empowered consumers will bypass primary care altogether and choose among a massive array of highly specialized services and technologies for illness care and wellness support.29 The preponderance of evidence suggests, however, that in the absence of the critical primary care functions, healthcare systems employing this approach will experience more fragmentation of care, duplication, and waste, as well as more inequitable health outcomes. Instead, we believe that strong longitudinal relationships will continue to be a major source of value in healthcare that directly contributes to technical excellence in the prevention, diagnosis, and treatment of disease; supports healthy lifestyle choices and adherence to beneficial treatment regimens, particularly for those whose agency is most constrained by structural inequality and other life circumstances; and holds significant independent value in patients’ experience of care.30
The primary care revolution must respond to these forces, facilitated by changes in payment, practice redesign, and innovative uses of technology.31 Primary care must assert itself as the only viable solution to the interrelated problems of rising costs, renewed biomedical technological innovation in the direction of more personalization, public demand for convenience, and widespread waste. The essential functions of primary care will be just as relevant to the future of healthcare as they have been up to now. Thus, the task at hand is to optimize for these functions, in addition to technical excellence in the prevention, diagnosis, and treatment of disease. Doing so in a way that enables financially sustainable care at the massive scale needed to adequately serve all U.S. citizens will require an unsentimental reexamination of how the competencies, actions, information, and power in primary care and the rest of healthcare are distributed among people and technology. We concur with others32 that the next few decades will witness a significant transfer of power, knowledge, and activity from the most specialized providers to patients, with primary care serving as the key fulcrum in the transfer. This is not to say that there will be no specialists in the future, but rather that they will increasingly be leveraged to assist with the most complex diagnostic and management challenges, while primary care teams and patients are empowered to manage routine cases.
To inform healthcare stakeholders, we offer four principles to guide the primary care revolution. These principles are derived from our own experience as primary care physicians and leaders, synthesis and analysis of existing evidence (including what already works well in service industries outside of healthcare), and knowledge derived from an in-progress program of mixed-methods research studying high-functioning primary care systems.33 (See Table 2 for an illustration of how the principles would manifest in the care of a patient.)
We have focused on the justifications for the primary care revolution and how it will manifest in terms of improved care, leading to better health outcomes and patient experience at a sustainable cost. Achieving this transformation in clinician and patient activity and interaction, however, will require more than better technology and payment approaches. This change will require highly effective leadership, management, advocacy, and continuous process improvement from the front lines of care to the most senior levels of management and policymaking.56 As these skills and competencies have not been emphasized in the education of healthcare professionals, this transformation must be supported by considerable evolution in workforce training,57 , 58 and it is essential that trainees receive clinical training in organizations that model the future of high-value care delivery.58 Change is never easy, and dramatic change to something as personal as healthcare is likely to be accompanied by considerable distress for all involved, particularly for those whose livelihood is at stake. Nonetheless, we believe that physicians, particularly those early in training or practice, should view this revolution with considerable optimism and excitement, for it holds the promise not only of considerable improvement in the experience of our daily clinical work, but also of our profession drawing closer to its highest ideals of humanism and scientific rigor.
This article was supported in part by the Harvard Center for Primary Care and by a grant from the California Health Care Foundation to the Journal of General Internal Medicine (administered through UC Davis). The views expressed herein do not necessarily reflect those of the Foundation, JGIM, or SGIM. There have been no prior presentations. The authors are grateful to Jessica Alpert for assisting with the preparation of the manuscript, and to Erin Sullivan, PhD, who reviewed earlier versions of the manuscript.
Dr. Ellner is the cofounder of Firefly Health, a for-profit, primary care service and technology company.
Dr. Phillips has no potential conflicts of interest to report. In addition to his role as director at the Center for Primary Care, Dr. Phillips serves as an advisor to CareMessage, a non-profit start-up organization that uses information technology to support the efforts of healthcare organizations to simplify care management.