Q&A: The root causes of problems in primary care

“Financial neglect and excessively large patient panels” are the root causes of problems in primary care, according to Thomas Bodenheimer, MD, MPH, a professor of family and community medicine at the University of California, San Francisco.

Bodenheimer recently published two essays in Annals of Family Medicine about the challenges facing primary care and possible ways to strengthen it. The essays are based on his own clinical and policy experiences, interviews with hundreds of providers and medical staff, and other evidence.

Though it seemed that primary care was entering a golden age during the first 20 years of this millennium, Bodenheimer wrote that the field now requires fundamental change.

As he explored practice changes that might benefit primary care, Bodenheimer discussed diffuse initiatives that he wrote “have enjoyed limited success, but have failed to address low primary care spending and excessive panel size.”

The first diffuse initiative he discussed, the patient-centered medical home (PCMH) model, includes standards like continuity, knowing your patients, team-based care and access. About 13,000 clinics in the U.S. use the PCHM model, according to Bodenheimer, but there is limited evidence demonstrating its impact on patient care.

The next initiative, accountable care organizations (ACOs), include “groups of doctors, hospitals, and other health care providers who come together to provide coordinated care to their patients,” according to Bodenheimer. He wrote that ACOs showed some improvements in financial performance in 2019, but that savings “may be overstated” since “ACOs can ‘cherry pick’ healthier patients, lowering their costs in order to benefit from shared savings.”

The final initiative, Comprehensive Primary Care Plus (CPC+), was launched by CMS in 2017. CPC+ is a 5-year program that supports more than 3,000 practices, all of which “are required to address access and continuity; care management; comprehensiveness and coordination; patient and caregiver engagement; and planned care and population health.” Though this initiative hoped to stimulate alternative payment models, most CPC+ revenue remained fee-for-service in 2018.

Healio spoke with Bodenheimer to learn more about the details of his essays.

Healio: In part one, you write that “some wonder if primary care is actually doable.” Will you expand on that? And what do you think?

Bodenheimer: Primary care is doable if the clinician is fast, efficient, has patients who are not too sick, has some kind of team that provides substantial help, and the clinician works less than 10 half-days per week so there is some time to recover from the overly busy patient care times.

Healio: You mention that primary care is often seen as too much work for too little reward, and that other specialties can be more attractive. As we face a shortage of primary care providers, what changes should be made to attract more?

Bodenheimer: Primary care incomes are generally OK except for med students with significant student debt, but the problem is the disparity between primary care incomes and incomes of some procedural and surgical specialists, which can reach over $500,000 per year. Those incomes need to come down so that med students don’t see such an income gap between primary care and those specialties. More important is the grueling work-life in primary care. Medicare, Medicaid and private insurers paying for scribes could have a huge impact on work-life.

Healio: None of the diffuse improvement initiatives appeared to have a significant impact on primary care spending. Do you think it is still worth PCPs’ time to implement any of these initiatives in practice? If so, which ones?

Bodenheimer: None of those initiatives has shown themselves to make a difference. An exception is CPC plus, which has brought additional money into those practices that are part of that program. But the program costs Medicare money, so it probably won’t continue.

Healio: What can PCPs start doing now to overcome these pressing issues in primary care?

Bodenheimer: Again, scribes can really help with documentation burden. Also, the website STEPSforward has good suggestions for overcoming some of primary care’s problems.

Healio: Are there any initiatives or proposed legislation that you recommend PCPs advocate for to advance the field?

Bodenheimer: Legislation that does not allow the AMA’s RVS Update Committee (RUC) to determine how much primary care vs. procedural specialists are paid. The RUC bakes into the payment mechanism enormous biases for specialists. The best thing would be to eliminate the RUC and have Medicare set payments. That would be important. Also, legislation that allows nurses and pharmacists to prescribe chronic disease medications under standing orders so that they can truly share the care with physicians — that would be legislation at the state level.

References:

• Bodenheimer T. Ann Fam Med. 2022;doi:10.1370/afm.2858.
• Bodenheimer T. Ann Fam Med. 2022;doi:10.1370/afm.2859.