The promising future of financing for whole-person primary care

For the nation’s struggling primary care system, help is on the way. This may sound too good to be true, but it’s for real.

The devastation wrought by COVID-19 — including the loss of more than 1 million American lives — has finally driven home the frightening reality of the health care crisis as nothing else during my 40-year career in primary care.

A massive new infusion of money will begin flowing into primary care via revamped payment systems targeted to establish value-based care, with most of the money aimed at replacing fee-for-service with team-based, high-quality, whole-person care models. This funding will be an unprecedented opportunity for primary care clinicians and system administrators to really do what they do best. But only those who reevaluate and redesign their practices will be able to take full advantage of it.

The nation’s business, political and health industry leaders have become painfully aware that a system that spends an astounding $4.3 trillion annually — 18.3% of total GDP — is still failing to keep us healthy. Since 2015, with the most expensive health care in human history, America has suffered an historic decline in life expectancy, leaving us behind virtually all our peer nations.

The urgency is sinking in for our decision-makers. New payment models focused on value-based care are already being developed by Medicare, HHS and about a dozen state governments. And they will be game changers. This infusion of money will be aimed at the underlying determinants of health; those social and behavioral drivers of chronic diseases that consume vast amounts of our resources, such as obesity, diabetes, hypertension, cardiovascular disease, addiction and chronic pain.

These efforts are bolstered by a recent National Academy of Medicine (NAM) report, “Valuing America’s Health,” which sounded an alarm calling for the transformation of health care financing through massive — and smarter — investment. The NAM report expert panel concluded that this is the only way to fight huge systemic problems beyond COVID-19, including the growing burden of chronic diseases; the opioid epidemic and other “deaths of despair;” racial and socioeconomic health inequities; and the persistent cost-ineffectiveness of health care financing.

The NAM report said the system can be saved only by serious disruption, and it proposed revolutionary yet reasonable recommendations. Among them: reducing by 50% health expenditures that do not actually improve health; increasing by 50% the spending on “social interventions” that are proven to improve health; and tying 75% of health care provider and plan revenues to performance metrics based on the most important health and well-being outcomes.

Revolutionary? I would say these are commonsense recommendations, and the committee prioritized those that were most feasible and likely to have the broad impact we need.

This is not a pipe dream. It is a true movement that is gathering momentum. I recently attended a primary care summit of health care leaders at the National Academy of Sciences and came away with a clear sense that the delivery of major new funding is no longer a question of if, but when.

As primary care physicians, we know we are working in one of medicine’s lowest paid and least glamorous fields. Nonetheless, some of the country’s largest multibillion-dollar corporations realize there is big money to be made in primary care. Amazon, Walmart and CVS are just a few of the giant companies that have paid tens of billions recently to gobble up primary care centers and large doctors’ groups, figuring they can run them more efficiently and profitably.

But will they deliver on health? Not unless they provide comprehensive, whole-person and whole-population-based care. If the corporate takeover of nursing homes in the past decades is any guide, we know this could result in a disastrous decline in the quality of care. It does not have to be that way, and there are successful models that show how the health system could move toward the elusive “Quintuple Aim” of improved patient care, better outcomes and lower costs, along with health equity and greater clinician well-being.

Innovative new models for primary care point the way toward the future. For example, the Veterans Affairs has improved outcomes and lowered costs by nearly $5,000 per patient annually through a team-based Whole Health approach. That approach, now being adopted by non-VA centers, examines each patient’s individual needs and offers holistic, integrative care across the spectrum of physical, social, behavioral and even spiritual needs. These models are not isolated to the VA and are cropping up all over the globe. Models like these will be most able to tap into the coming funding.

Whole-person care is taking shape beyond government programs, blossoming throughout the country. An article that I recently co-authored in the Journal of the American Board of Family Medicine reported the results of a year-long study of an Integrative Health Learning Collaborative involving 16 clinics that treated 942 patients using an approach adapted from the VA Whole Health model. Rather than employing the traditional SOAP note (subjective, objective, assessment and plan), the clinics adapted the more personalized HOPE note (healing-oriented practices and environment), which identifies what truly matters to a patient as the first step toward promoting effective self-care. After a year, practitioners reported improvements in their clinical practice, their skills and attitudes, and their support for change management. This is exactly where we want to be going.

Change is inevitable. But the new money flowing into the system will go to only those in primary care who can demonstrate that they can get results; that they can make people healthier, not just lower costs. This is our future, whether you are in private practice or, like some 70% of primary care doctors, are part of a health system or medical group.

Now is a time for self-examination of our work. Are we equipped to adapt our practices so that we are truly able to take care of people in the way we intended when we first went into medicine? Or if we work for a medical system, how can we push our employers toward meaningful systemic change toward whole-person primary care?

I encourage you to consider the change you can implement, and then join me in being part of that change.

References:

• CMS. NHE fact sheet. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet. Accessed Sept. 6, 2023.
• Council on Foreign Relations. U.S. life expectancy is in decline. Why aren’t other countries suffering the same problem? https://www.cfr.org/in-brief/us-life-expectancy-decline-why-arent-other-countries-suffering-same-problem. Published Sept. 8, 2022. Accessed Sept. 6, 2023.
• Healing Works Foundation. The HOPE Note. https://healingworksfoundation.org/resources/hope-note/. Accessed Sept. 6, 2023.
• Jonas WB. J Fam Pract. 2020;69:493-498.
• Jonas WB, Adibe B. JAMA Health Forum. 2022;doi:10.1001/jamahealthforum.2022.1109.
• National Academies of Sciences, Engineering and Medicine. Achieving whole health. https://nap.nationalacademies.org/catalog/26854/achieving-whole-health-a-new-approach-for-veterans-and-the-nation. Accessed Sept. 6, 2023.
• Rosenbaum E, et al. J Am Board Fam Med. 2023;doi:10.3122/jabfm.2023.230007R1.

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Wayne Jonas, MD, is president of Healing Works Foundation.