CT VIEWPOINTS by H. ANDREW SELINGER M.D.
If primary care medicine is to continue to serve the people, then it must evolve and transform. A good primary care clinician is the trusted partner with whom patients build a strong and long lasting relationship. This relationship has been the foundation of the physical and emotional healing power of clinicians since the dawn of ancient medicine in Egypt over 6,000 years ago.
The need for empathy, understanding, respect and patient education has not wavered from then to now. What has changed is the overwhelming accumulation of medical knowledge, skill, and the ability to apply biomedical science to more effectively treat disease.
Biotechnology permits us to improve the quality of life and greatly extend life. With this ability comes an ever increasing responsibility to be a careful steward of healthcare resources.
I am often dismayed to see the intensified efforts to advertise to consumers for every possible medical service under the sun. It seems that every hospital and health system needs to trumpet their centers of excellence. In Connecticut we now have Yale Health, UConn Health, Hartford Healthcare, Trinity Health and Middlesex Health to name the major players.
They advertise more centers of excellence than anyone could keep track of; CancerCare, Men’s Health, Women’s Health, Bone and Joint Health, Wound Care, Breast Health and Wellness, etc. — often duplicating one another and vying for your business.
You would think that the sum of a human being is nothing more than the sum of their parts! One could argue that these health systems are all well intended but make no mistake, they all have their eye on the bottom line and strive to each grow their “book of business.”
And this business is not primary care.
The International Organization of Economic Cooperation and Development (OECD) determined that the average percent of the health care dollar spent on primary care in their 34-member industrialized countries was 14 percent – in the U.S. in 2016 it was only 7.7 percent and in Connecticut only 5 percent!
In 2017 in Connecticut less than 31 percent of physicians in the state provide primary care. The generally accepted optimal percentage… 50-60 percent! It is well known that in the U.S. most of our quality indicators lag those of the other industrialized countries. What are we doing…?!
The driver for all of this is the fee-for-service payment system that encourages volume and cares little for delivering value. Add to this the rapid escalation in pharmaceutical drug pricing and hospital costs and we have a devastatingly wealth draining industry.
Have we forgotten the truism that “a rising tide raises all boats?” Have we forgotten (or did we never know) that good health begins in the home and the community and NOT in these silos of care that are too often “high tech and low touch?”
Accessible primary care is essential to support patients in their home and community, to enable lifestyle changes that promote and maintain health and to effectively manage chronic illness. All too often it’s the social fabric of one’s life that determines our health.
The time is NOW to change course in Connecticut, to redirect funding for primary care to inter-professional teams (physicians, behavioral health practitioners, social workers, community health workers, nurses, pharmacists and nutritionists etc) who each work to the top of their licenses and training. This means delivering flexible up front financing of primary care — to uncouple the existing rigid payment system requiring face-face office -based encounters and deliver and pay for care delivered in the right setting, at the right time and by the right healthcare professional. Examples of this include home visits for the elderly and disabled, transportation support, specialty remote video consults, telemedicine patient data transmission, nutrition counseling and many other services that directly impact health. Why even an air conditioner purchase for a pediatric asthma patient qualifies!
A seismic change in our healthcare system is occurring as we embrace the concept of population health. Population health is an approach to health that aims to improve the health of entire populations of patients and not just focus on the one individual in front of you, and ONLY for that moment. All diabetics who need regular monitoring, all adolescents who require important vaccinations, women who need periodic mammography and adults over 50 due for colon cancer screening are just a few examples. Never lose sight of the importance of the individual therapeutic relationship, but leverage technology to reach out to entire patient groups.
All of this and more is possible with flexible reimbursement strategies.
We cannot delay any longer. Primary care is the linchpin of an effective healthcare system, care that must be continuing and comprehensive health care for the individual and family in the context of culture, lifestyle and community.
H. Andrew Selinger M.D. is Chairman of the Department of Family Medicine at the Frank H. Netter MD School of Medicine, Quinnipiac University.