The Future of Primary Care in Massachusetts

By Barbra G. Rabson

(October 2019)

Lately, I’ve been thinking a lot about the future of primary care in Massachusetts. I was inspired in part by work we’ve been doing at MHQP to explore barriers to affordability through the patient’s eyes, and lack of access to primary care was one of those barriers. In fact, I wrote a bit about this in a recent post.

Access to primary care has also been a major concern discussed at the Massachusetts Employer Health Coalition, where I sit on the steering committee. This statewide consortium of Massachusetts employers and other stakeholders is focused on improving the appropriate use of the emergency department as a strategic step toward promoting a more affordable health care system, a goal that cannot avoid intersecting with primary care.

So, my mind was ripe for more provocation. That provocation came like a wave in the form of several stimulating publications that sparked my thinking with some fresh perspectives in recent months:

Convenient Care: Opportunity, Threat or Both?, a NEJM Catalyst article by Ateev Mehotra and Edward Prewitt, which discusses the results of a survey of the NEJM Catalyst Insights Council about new models of convenient care. Responses revealed conflicting views about both the value of convenient care and what respondents believe their organizations should do about the proliferation of convenient care options. Convenient care has clearly disrupted healthcare institutions in fundamental and important ways, and primary care practices have still not yet fully determined how to adapt to this new challenge.

In a similar vein, The Evolution of Primary Care: Embracing Innovation While Protecting the Core Value, a NEJM Catalyst article by Steve Strongwater and Joe Kimura, highlights the fact that primary care’s value system (based on four key elements defined by Barbara Starfield: first contact, comprehensive, coordinated and continuous) is being disrupted by new entrants looking to exploit innovation opportunities to address gaps in value. The authors suggest that telemedicine providers, urgent care centers, medical apps, mobile paramedical programs, and other initiatives “seek to identify and attack inefficiencies and thereby simplify the complexity and dysfunction that we have come to accept” in our primary care system.

This “complexity and dysfunction” is further addressed in Reframing Healthcare, a new book by Zeev Neuwirth, which posits that primary care is trying to do too many things to be effective at any of them. Dr. Neuwirth identifies five  “brands” he believes primary care is attempting to fulfill – on-demand urgent care, wellness care, complex-chronic care, continuity care and condition-specific care. Because the infrastructure, systems and processes required to provide each of these service areas differ significantly, the author claims that “Despite how different each individual patient’s issues are, this one primary care practice is supposed to be everything for everyone, everywhere, all the time. But this construct struggles to provide highly effective, highly efficient, high-quality service in these wildly different domains of clinical care.” (p. 98)

As further context, Ishani Ganguli, Thomas Lee, and Ateev Mehotra published an important paper, Evidence and Implications Behind a National Decline in Primary Care Visits, in the Journal of General Internal Medicine. This article documents a national decline in primary care visits between 2008 and 2016 of 6–25% across a range of populations in five sources of national survey and administrative data. The authors “hypothesize three likely mechanisms behind the decline: decreases in patients’ ability, need, or desire to seek primary care; changes in primary care practice such as greater use of teams and non-face-to-face care; and replacement of in-person primary care visits with alternatives such as specialist, retail clinic, and commercial telemedicine visits.”

In another article, Will Increasing Primary Care Spending Alone Save Money? in the Journal of the American Medical Association, Zirui Song notes the lack of strong empirical evidence that spending more on primary care as it is presently structured will slow total healthcare spending.

Lastly, a study from the Milbank Fund that shows the differences in primary care spending by state Medicaid programs and highlights the underinvestment in primary care.

Since all stakeholders (patients, provider organizations, health plans, policy makers) depend on primary care as the foundation of our healthcare system, it is incumbent upon all of us to assess, track and understand what is happening to the primary care system in our state and be prepared to support it as needed.

Collectively, these publications, along with a discussion with MHQP’s Physician Council, have caused me to focus on some critical questions related to the stability and future of primary care in Massachusetts:

  1. Are primary care visits declining in Massachusetts as they are nationally? If so, do we understand the reasons for the trend?
  2. Do mini-clinics, telemedicine apps and other convenient care systems fill a void that standard primary care cannot fill? If so, what should primary care’s response be? Are these alternative delivery options saving money or adding costs to the system as a whole? What is the impact on the quality of patient care? How would we need to modify our primary care models to more effectively address patients’ needs?
  3. What changes do we need to make to reimbursement as a critical driver impacting the future of primary care? Given the disconnect between the timing for the ROI on primary care programs and actual improvements in health, what changes need to be made to payment models to allow for effective investments in primary care? Why has the Massachusetts market not been conducive to some innovative primary care models?
  4. Is primary care trying to do too many different things and as a result not doing some of them well? What roles do we ultimately need and want primary care to play? How can we redesign the primary care system to be more focused on its key roles and unique contributions to the wellbeing of patients?
  5. What are the aspects of primary care that provide the most value to patients and efficacy to the system? What steps should we take to preserve what we value most about primary care?

Time to Take Action

I call for us to have a dialogue among the many stakeholders in Massachusetts healthcare about what we want the future of primary care to look like in our state. We’ve been out in front in the nation on so many issues – let’s make this the next one! Clearly our models are outdated and we need to take a fresh look at what’s next for primary care. The trajectory is concerning and it is time to take action to strengthen primary care in Massachusetts. If we are intentional about what we want primary care to look like and put our collective best feet forward to re-stabilize the primary care system, we can preserve it as the foundation of high quality, cost effective care for patients everywhere.

Please email me at brabson@mhqp.org.org if you would like to join us in this effort.  Thank you.

2019-10-08T18:50:54+00:00