Challenges in Primary Care

The world, and especially the U.S., is facing a total crisis when it comes to primary healthcare. There are a few contributing factors that have come together to create a dire situation. First, as time has progressed, we have learned more and more about healthcare, discovering hundreds of thousands of diseases. There is now so much information about health that no one can know it all.  This increase in knowledge has led to the creation of dozens of specialties within the healthcare field. As the healthcare field diversifies, fewer and fewer physicians are choosing to work in primary care. Understandably so, given that primary care providers are more often overworked, and they also make significantly less money than specialized physicians.

Why is this a problem? Well, primary care is actually the most important kind of healthcare. The purpose of primary care is to keep us healthy by catching minor health issues as they arise and preventing them from becoming more serious, chronic ailments. Some refer to this as the Wellness Cycle. However, in today’s healthcare landscape, we are stuck in an Illness Cycle – treating illnesses over long durations once they have become more advanced. This results in more pain, more treatments, and more medical bills for patients, and causes healthcare systems to have very high expenditures for providing care. Consistent primary care is the key to preventing this cycle from happening, and ultimately creates significantly lower healthcare spending over the long term.

However, in addition to a shortage of primary care physicians, the U.S. faces a huge challenge in access to healthcare. While the government funds healthcare insurance for vulnerable populations, such as the elderly, low-income people, and people with disabilities through the Medicare and Medicaid programs, those programs are not completely free and still leave a large portion of the population uninsured. According to the Center for Disease Control, 30.1 million people under 65 (11.1%) were uninsured in 2018.¹ For many, lack of insurance coverage means not being able to afford copays and other costs associated with receiving medical care. Unfortunately, this often leads people without insurance to put off visiting a doctor until they have an emergency – which can end up costing thousands of dollars in out-of-pocket costs and exacerbating poverty for families when a medical emergency arises. For anyone without health insurance, it is still important to receive preventive and primary care, and there are options available that offer services free-of-charge. Sites such as freeclinics.com can help with locating free or reduced-cost healthcare services of every kind. 

Even for those who are fortunate enough to have health insurance, costs can still prove unaffordable. Furthermore, the fee-for-service payment model of the U.S. healthcare system has eroded patient trust in their physicians’ recommendations. With the knowledge that providers receive more money for providing more expensive or extensive treatments, patients are often wary of whether they really need treatments or procedures physicians suggest to them. The discovery of illegal referral kickback schemes that compensated primary care physicians for referrals to specialists also impacted overall trust in the referral system. While rare, public knowledge of these schemes has certainly created uncertainty in patients’ minds about whether they really need that extra test, prescription, or treatment. In fact, physicians often do recommend more testing or treatments than are necessary due to the litigious nature of American society – to protect themselves from potential malpractice lawsuits, they recommend tests or likely unnecessary care to avoid negligence claims on the off chance a very unlikely problem arises that could have been detected earlier from a test.

The Path Forward

So, how can we improve patient trust in their physicians and help them reap the benefits of primary care? First, expanding the use of bundled payment models could relieve the financial temptation that struggling physicians can succumb to by providing an all-encompassing payment per patient for all medical care provided. This payment structure is the opposite of fee-for-service, grouping all services into a set compensation bundle for each patient. Some areas of healthcare have already began to use bundled payment models. Studies have found that bundled payments significantly reduced costs for lower extremity joint replacements but not for more complex conditions. Refinements to the models could include better accommodation of risk stratification and expanding bundled payments for simpler procedures or non-chronic conditions.² 

Second, shared decision-making can help patients make more informed choices about their healthcare journeys. This practice requires better education and transparency with patients about their treatment options, and the pros and cons of each option. Many patients, especially older ones, want to avoid overuse of healthcare – even with awareness of potential risks to their health down the line. To avoid the fear of lawsuits, patients could sign a waiver acknowledging that they understand possible health risks associated with opting out of certain tests or treatments. Increasing the amount of education patients receive about preventive services or treatment options can go a long way in helping patients feel equipped to make the right choices about their healthcare.

The expanding use of telehealth visits and SMS-based chatbots have expanded access to healthcare consultations, especially in more rural or remote areas. These technology-based solutions are helping more patients receive medical advice no matter where they are – however, we must be wary of inequities in the quality of care. Telehealth consultations are only possible for patients who have a smartphone or computer and internet connection. This blocks many lower-income or rural communities from accessing this convenient new way of receiving healthcare. As technological advances provide new ways of providing healthcare, intentional measures must be taken to prevent inequalities in care based on income or location, such as expanding access to health insurance and providing technological infrastructure to enable rural communities to leverage AI and other digital healthcare capabilities.

The challenges within primary care are complex and require solutions from many angles. Expanding access to primary care will be vital to improving health outcomes and reducing overall healthcare expenditures. Changes in payment models, patient-provider relationship dynamics, and use of technology can all play a role in enabling better primary care.

Sources:

1. National Center for Healthcare Statistics. “Health Insurance Coverage.” Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, 2018, 2018. Centers for Disease Control and Prevention, www.cdc.gov/nchs/fastats/health-insurance.htm. Accessed 23 May 2020.
2. Advisory Board. “Do bundled payments actually reduce costs? Here’s what a new review found.” The Daily Briefing, Advisory Board, 9 Jan. 2020, https://www.advisory.com/daily-briefing/2020/01/09/bundled-payments. Accessed 23 May 2020.