Although primary care is the lifeline of a health care system, the United States spends less on it and more on specialty care than other high-income countries. This sends a message to our primary care workforce: we don’t value what you do.
The result? Burnout, high turnover, physician shortages — all of which were dire crises before the pandemic but are even worse now.
On the latest episode of The Dose, host Shanoor Seervai asks Asaf Bitton, M.D., executive director of the health innovation center Ariadne Labs, what it will take to rebuild the nation’s broken primary care system.
“What we’ve learned over these last 15 or 20 years is that primary care is a team sport,” says Bitton. A modern practice cares for a well-defined population using “technology in a different way . . . to start building a much more integrated primary care of the future.”
Transcript
SHANOOR SEERVAI: Primary care doctors are the gatekeepers of our health, both at an individual level and as frontline guardians of our health at large. Throughout the pandemic, many primary care doctors have been working round the clock under terrifying conditions.
Burnout is setting in. And even prior to the pandemic, primary care providers in this country were wrestling with the complex realities of our health care and payment systems. I’m Shanoor Seervai, and on today’s episode of The Dose, we’re going to talk about what it will take to rebuild the primary care system in the U.S.
My guest, Dr. Asaf Bitton, is the executive director of Ariadne Labs, a health systems innovation center at Brigham and Women’s Hospital and the Harvard School of Public Health. He’s also a primary care physician and a professor of medicine and health policy at Harvard.
Dr. Bitton, thank you so much for joining me today.
ASAF BITTON: It’s a pleasure to be here.
SHANOOR SEERVAI: So let’s talk first about the role of primary care in the U.S. — how it is delivered and how that might be improved. And then we’ll move on and talk about the people who are delivering that care. So how are we doing? Are the resources for health care in the U.S. being well-spent?
ASAF BITTON: It’s unfortunate, but the reality is that we’re not doing all that well right now. You know, we certainly are a country that spends way more on the delivery and provision of health care than any other country in the world. But how we spend that is also pretty unusual. We spend a lot more than almost every high-income country in the world on specialist care, hospital care. And we actually spend quite small amount of our health care dollars on primary care.
The best estimates are that we probably spend around 4 to 5 percent of total health care expenditures on primary care. And for our Medicare population — over 65 on dialysis, high needs, many conditions — we actually spend even less: we spend only about 3 percent of the total health care dollar. So we certainly do not have it subdivided in a way that supports this critical part of the system. And the reality gets even more tricky when we look at the potential benefits that we’re leaving on the table. There is good evidence that areas at the county level that have higher densities or higher proportions of primary care physicians and primary care teams, actually controlling for everything else, have better life expectancy. And that increasing the density of primary care is associated better life expectancy.
So there are not too many things that we can actually invest in on the health systems level that improve life expectancy and also, which primary care does, increase equity in populations. And yet, we’re seeing the opposite in terms of investments and focus at the policy level, where we’re seeing actually the primary care workforce in significant crisis, a lot of people leaving, not enough people in the pipeline, and the finances and the structure of primary care practice under severe strain. All of this even before COVID, but now certainly during COVID.
SHANOOR SEERVAI: Right. And I want to talk about how to fix it, but first let me ask you, how did it get so upside down and what are the consequences of not spending enough money on primary care?
ASAF BITTON: Well, you know, in some ways primary care is a little bit like oxygen. You only start to notice it in its absence or when there’s not enough. By its definition, as an interlinked set of functions delivered with and for communities in partnership, functions that are really addressing first contact access, continuity, coordination, comprehensiveness, and person-centeredness. Those functions — or we call them the five C’s — are not the things that our payment system is set up to easily pay for or measure. And they’re not the things that are sort of most valent to a lot of people going into the medical and nursing disciplines.
We have a health care system that is structured and prioritized toward sick, acute care, as opposed to holistic, comprehensive, often preventive community-based care. And so it starts, in my opinion, with how we value and how we price and pay for services. We actually atomize services into units of visits and units of hospitalizations and procedures and tests. And that atomization is a function of sort of idiosyncratic U.S. payment history, but has enormous effects because when you start to add up the accounting ledgers and roles underneath our current system, which is fee for service, all these little services turn out to not get paid for as well in something like primary care as they do in something like acute and specialty care. So it starts with the way we pay for and value it. But it’s more than payment. It’s actually revolving around whether we prioritize sick care or promotive, proactive, preventive care. And I think that’s a big reason why primary care has sort of fallen behind in prioritization and in remuneration.
SHANOOR SEERVAI: And was this the conversation that people were having about primary care before COVID?
ASAF BITTON: Absolutely. You know, we used to be a health care system 60, 70, 80 years ago that was principally structured, at least in the medical field as at least a plurality, if not majority, general practitioners. But with increased specialization, technological focus, with the movement of care into and around hospitals as the center points for both training and health care activity in the United States, without commensurate focus, funding, and prioritization at the community level, let alone at the level of integration between public health, social services systems, and health care. What we had found is the increased atomization and specialization and fragmentation of U.S. health care. We principally still have across the U.S. a fee-for-service-based system that does not reward, acknowledge, or value the valuable care that primary care clinicians provide.
SHANOOR SEERVAI: And you are a primary care physician, and you’ve obviously thought about this a lot at this level of policy. But at the level of your practice, what could primary care look like after the pandemic or at least as we learn to live with it?
ASAF BITTON: Well, you know, the good news is that, in part because of the necessary push to revitalize primary care, even before the pandemic, that’s been going on well, in primary care pediatrics for 30 years, with the patient-centered medical home, with family medicine for 20, 25 years, and internal medicine for at least 15 years, we’ve understood that the modern practice of advanced primary care has to encompass way more than a 15- or 20-minute visit within the four walls of the clinic with a mostly stationary team of clinicians that mostly just sees whoever walks in the door. What we’ve learned over these last 15 or 20 years is that primary care, to meet its population and individual care goals, it’s necessary for it to be a team sport, enabled by more effective and advanced health information technology and enabled to encompass more than just a reactive, visit-based mentality, and can be transformed to a proactive, team-based, IT-enabled endeavor in which practices know who they care for. They have a defined population that they reach out to, whether or not those populations come into the walls of the clinic. And they use technology in a different way and are able to start building a much more integrated primary care of the future.
SHANOOR SEERVAI: Can you give me an example of how you’re doing that in your practice?
ASAF BITTON: I practice at a community-based practice in urban Boston that’s part of a large academic health system. And what we realized was threefold. Number one, that the modern practice of primary care as we just discussed needed updating. Number two, that in order to meet the increasing needs of a population of people who have multimorbidity, health-related social needs, and for whom just visits themselves were not the answer, we had to build a different model. And then the third part of it, and this might be Massachusetts-specific, was that our health system had just signed accountable care organization contracts. And that meant that for the first time, the health system for defined an increasing proportion of its patients, was actually on the hook for their outcomes and for their total cost of care.
So in response to that we built this clinic, completely restructured the team allocations so that every team had not just a doctor and a medical assistant, but a nurse, a social worker to do integrated behavioral health. There were shared resources, such as community health workers to do outreach. There were population health managers to use the backend of electronic health records to see who was due for colorectal cancer screening, who needed a statin, etc. To actually shut the clinic down for two hours every Wednesday and meet to look over data. Not to see patients, but to look over data, review quality improvement projects, and host a patient advisory council to help us know what are the ways that we need to work on together to better serve our population.
So those are just some of the ways in which we reimagined care and are reimagining care. And we’re not an outlier anymore. Whether it’s regional learning collaboratives or even affiliated large federal model efforts, such as those out of the Center for Medicare and Medicaid Innovation in which CMS, along with other affiliated payers, are testing what happens when you start to pay differently for this type of integrated care across different payer landscapes and help practices move toward this transformation effort.
SHANOOR SEERVAI: I want to talk more about payment in a minute, but I just want to come back to something you said about the population you were serving, and you mentioned comorbidities. And I can’t help but think about all the inequities that the pandemic has surfaced, and all the people who’ve been worst hit. So, are we seeing initiatives to address these inequities?
ASAF BITTON: I think we’re certainly seeing these initiatives to rebuild, to try to improve vaccine access, testing, and COVID treatment access. But I will be direct with you. I don’t think we’ve seen the focus necessary at the level of primary care policy and payment at any of this local, state, or federal levels to really address what everyone is saying, appropriately, is an equity mission. But I would argue perhaps is not seeing with a policy and payment focus, the commensurate and necessary focus at the primary care practice level on the levers and supports needed to help practices through this pandemic.
SHANOOR SEERVAI: So, is there something that you think could be done to address these inequities?
ASAF BITTON: It starts with payment to create the fiscal space for practices who are running on a treadmill of fee for service. Primary care practices have, you know, 1 to 2 percent margins; they’re mainly in a volume visit sort of mindset, the majority of them. And it’s very hard to ask them to continue to do more, to take care of more patients and more integrated, higher-level functions. While, for instance, what we’ve seen in the pandemic, we’ve seen, you know, between 2 and 5 percent of practices having to close at any one time, we’ve seen 20 percent have incredible financial challenges, 40 percent have furloughed workers, 50 to 60 percent of primary care clinicians of all stripes are reporting massive amounts of burnout. People are leaving. People are suffering. And it starts with payments.
So primary care is really in need in in many ways of a combined rescue package. Combined because it’s needed by local payers who understand the value of primary care, but sometimes don’t remember to include it in their payment contracts. It’s needed at the level of accountable care organizations that sign these contracts, but then don’t often help funds flow down to primary care to enact so much of the proactive, population-based care. And it’s needed at the federal level, with federal payment changes. And there’s even legislation that’s under discussion to help revitalize this sector, help promote the provision of community-based care, hire community health workers, and help in the integration of data flows and referral capacities between primary care and public health.
I mean, these are massive undertakings. There’s a workforce pipeline issue. But we have a blueprint. You know, finally after 25 years, the National Academies of Sciences, Engineering, and Medicine commissioned a report for the first time on sort of how to implement a high-quality primary care of the future for the U.S. Full disclosure: I was on that committee. And beyond payment, one of the key parts, and we’re happy to see this, is that there really needs to be an integrating and accountability mechanism within the federal government. And we’ve actually seen that happen, after the release of the report, in the appointment of a coordinating function within HHS to start to think about primary care policy all across the different agencies, as opposed to siloed within one or the other.
SHANOOR SEERVAI: So, am I hearing you say that the biggest challenge for primary care workers is payment?
ASAF BITTON: You know, I’m firmly in the camp that it starts with payment but doesn’t end there. Payment is a means to the ends that we wish to see. You can’t just ask health care payers and the health care system to prioritize what you’re doing, unless we in the primary care community are willing and ready to shoulder the challenge and the opportunity of providing advanced, team-based, community-integrated primary care.
I think the good news is that the primary care clinician community is willing and able and wants to do that. The way to start to get unstuck is to provide new fund flows, attached to new ideas, capacities, requirements of what we imagine primary care to be. But then I think there’s a third part, and that’s really around primary care stepping into its role as the central integrator, coordinator, and understanding and working with, not dictating and lecturing to the communities that we serve, to figure out how it is that we can provide them with the care that they need.
So for some communities, that may look like community health workers and embedded integrated teams. For other populations of patients, it might be virtual-first offerings or sort of primary care that’s much more technologically enabled. For yet another community, it might look different. And we have learned the hard way in this horrible pandemic that when you divide artificially the provision of health care from the provision of public health, in the pandemic or other health shock, bad things happen.
And in fact, the highest-performing health systems across the world and the country do two things consistently. Number one, they almost always — in fact, I can’t think of an example of when they don’t — they always have a strong primary care system, a strong primary care base, a well-funded primary care system. But they don’t stop there. They have an integration by both data, strategy, planning, and policy mechanism between their public health capacities and primary care. Imagine what COVID might’ve looked like if primary care had those integration capacities, was able to surface early warnings and cases, was able to get testing out into the community, was able to get community education out instead of just dealing with the deluge of cases and not even having enough — like so many clinics, including mine, at the beginning — not even enough masks to get through next week. It would have been a very different circumstance.
SHANOOR SEERVAI: Since you’re talking about investments, I have another money question for you. So, a new study just released using prepandemic data shows that the turnover of primary care physicians costs the health care system nearly a billion dollars each year. And about a quarter of that can be attributed to burnout. Tell me more about the economic case for improving the work conditions of our primary care physicians.
ASAF BITTON: Sure. I agree with that estimate. I would say perhaps that’s even a conservative estimate, honestly. The turnover . . . any physician may cost a system up to $250,000 in combined search cost, lost revenue, lost visits, lost . . . you know, all ways of counting. It’s an economic loss. It’s a fragmentation loss. It actually has a years-long tail. Because again, primary care’s ability to serve its community and serve society is prefaced on its longitudinality. On the fact that, you know, I’ve been in practice almost 20 years and I’ve had patients that I’ve known for almost 20 years. I’m able, my value to the system and to them, is anticipatory guidance. It’s trust. I mean, we’ve seen it in something as basic as vaccines, which move at the speed of trust, and why not involving primary care in the vaccine rollout was probably a mistake early on.
We’ve seen it all the way to high-cost, high-needs patients. Who is going to manage their care, if not a trusting, trusted primary care team? So when a clinician is lost, relationships are fractured, institutional and individual and personal health journey memories are lost. And the ties that bind our already fragmented system together are frayed just that much more. So to me, it’s almost an underestimate. But beyond quantifying the money is, what is the human and relational cost of losing practitioners that have served their communities for decades? That’s what I really worry about.
SHANOOR SEERVAI: So let’s talk about the pipeline, because we have this fragmented system and, does that disincentivize people coming out of medical school from choosing to practice primary care, or maybe they choose it to begin with and then they later opt to go for a different specialty or don’t want to stay with it because it’s so exhausting?
ASAF BITTON: My observation, teaching medical students, premedical students, and residents, is that there’s a huge number that come into medical school interested in the integrating kind of capacities of primary care to improve population health and individual health. They are excited about it. And then what happens though is that they get to the end of medical school and they start looking at a couple of things. They start looking at their debt burden, which in the U.S. can run into the $200,000, $300,000 range easily. They start looking at the relative remuneration of different specialties and realize that they can make three to four to five times more money to help pay down their debt burden and meet their family and individual needs by going into different specialties. And then they see the sort of relative respect and who’s higher on the hierarchy in many institutions, which are specialists. In which is this perception, quite incorrectly, that primary care is simple medicine, first kind of, you know, not so complicated, not so intellectually respected. And so we have to push against all of those.
And then people who go into residency then start to see that not only have they made a choice to make less money to serve communities in high need and have issues paying debts back, but also that the practice of primary care is really hard. And so that’s what we’re fighting against. And so it requires us think nimbly and to think resourcefully around, for instance, loan-forgiveness programs. Not just increasing primary care salaries, but paying back the debts, give people the invitation to walk through the door, to build the career with communities that they always wanted. And it also requires us to think about how to make these jobs sustainable, as opposed to rat races or hamster-wheel races where people are writing notes and taking phone calls at 11:00 P.M. at night.
SHANOOR SEERVAI: Is there a way to revitalize primary care with either pay or prestige?
ASAF BITTON: We’re seeing that across country, but as the makeup of who goes into medicine continues to change and evolve, and as people really come into this with more of a social public health, public policy, behavioral background, they want to make a difference in their communities. They’ve seen that communities are demanding the provision of equitable care, and they’re inspired by global health people like Paul Farmer, and we honor his passing because he was an inspiration to so many of us in the primary care world. But good will and good faith only go so far. At the end of the day, we need to help students of all health professions make this a tractable, tenable career. You know, basically helping to tell a different story.
SHANOOR SEERVAI: Dr. Bitton, thank you so much for joining me today, and I hope you’ll come back because I feel like this conversation could just keep going.
ASAF BITTON: I’d love to be back and I want to thank you for having me.
SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.