The Primary Care Crisis: What to Do?

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.

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.

Does Emotional Support Improve Health Outcomes?

Anyone who has been diagnosed with a chronic disease has experienced the unsettling cycle of emotions that accompany such often-shocking news. Fear. Anxiety. Denial. Depression. And in many cases, isolation. The feeling that no one can understand what you are going through.

No matter how life-threatening or relatively low-impact a diagnosis may be on one’s health, these feelings are a natural reaction to anything that promises to upset one’s equilibrium. We have routines, goals, and plans for the future. When facing a new diagnosis, we are subject to almost-certain change. Amidst navigating the decisions in how to handle our care, we wrestle with our fears and anxieties towards the future. While each individual will have different concerns on a micro-level, the overarching questions will be the same. Is my life in danger? How will my lifestyle be impacted by this diagnosis? Is the future I have planned at risk?

Usually, any diagnosis comes with some sort of care plan. Whether it’s lifestyle change, medications, or a more intensive treatment like surgery, physicians will recommend treatment options to address or improve a patient’s medical condition. Physicians will equip you with as much medical knowledge as they can to help patients make informed decisions about their treatments. And while good doctors will also ensure that patients feel taken care of emotionally, that responsibility is not included in a physician’s job description. Most hospitals have social workers, who help patients navigate any changes that come with a new diagnosis. These resources range from legal and monetary to practical to spiritual and emotional.

In many cases, mental health plays a huge role in a person’s ultimate health outcomes. Plenty of research has shown that emotional support impacts the overall effectiveness of patients’ treatments1. Health outcomes usually depend on how well we follow our care plans – the more we take our prescribed medicines, adjust our diets, and exercise, the more our health will improve. In light of all these changes, it can be hard to maintain a positive attitude, especially when facing a potentially terminal illness, financial stress, or other challenges. A human truth presents itself. When we feel depressed, we lose motivation. Without motivation, we stop following our care plans. The result is a downward spiral in care plan adherence, health condition, and emotional health.

What can break this negative feedback loop and bring back motivation? Hope. The assurance that someone has been through the same thing before and survived, or settled in to a new normal. Empathy. Talking to someone who understands. These kinds of connections can make or break an individual’s emotional capacity to fight through a difficult care plan or prognosis, thus affecting their physical recovery. While social workers and other hospital resources can alleviate some of the emotional burden on patients, true empathy can only come from speaking with others who have shared experiences. For example, Chicago-based nonprofit Imerman Angels provides one-on-one peer mentoring for cancer patients, survivors, and caregivers. With a large global database of volunteer survivors and caregivers, Imerman Angels pairs these volunteer mentors with individuals currently facing cancer or supporting a loved one. Their support seekers’ testimonials show the power that hope and empathy can have in overcoming life-threatening diseases.

Emotional support is often an opt-in addition to care. But empathy benefits everyone. If emotional support should were part of the standard of care, rather than an afterthought, I think we would see positive outcomes in care plan adherence and even survival rates.

References.

  1. Jane Turner, Brian Kelly. “Emotional dimensions of chronic disease.” West J Med. 2000 Feb; 172(2): 124–128. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070773/).