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I am a little late to the game on this 2021 report from the National Academies of Sciences, Engineering, and Medicine. But my tardiness does not diminish the appeal of the ideas that jump off the 428-pages of this document. These ideas, if implemented, would terraform the primary care landscape.
A reliable and effective primary care service is essential to the US healthcare system. Barbara Starfield taught that people-centered primary care focuses on health needs, enduring personal relationships, and comprehensive and continuous care. She believed that primary care was responsible for the health of all individuals in a community, regardless of their point in the life cycle.
As of 2022, the US has made limited progress toward Dr. Starfield’s vision. Clinician shortage is a major culprit, largely driven by the pay discrepancy that makes primary care less attractive to medical students. Another culprit is the lack of any federal agency to oversee primary care and dedicated research funding.
Building on the recommendations of a 1996 report by the Institute of Medicine, the 2021 NASEM report recommends that primary care become a common good, made available to all individuals, promoted by public policy, and fed with resources to achieve health equity.
The recipe for high-quality primary care laid out in this report is a delicious dream for advocates of integrated healthcare. Here are specific actions from the report that I believe fit well with the mission of CFHA:
- Design interprofessional care teams: The mission of CFHA is to make integrated care the standard of care across the US. Integration allows for multiple disciplines to work together as part of an interprofessional care team. Effective integration allows teams to work to the top of their respective skills, coordinate care across multiple settings, and meet the needs of communities. This kind of stuff is bread and butter for CFHA.
- Reform payment models: New payment models have taken hold in some parts of the US, but at a glacier-like pace. One way to accelerate this adoption of new models (part FFS, part capitated, in which clinicians are rewarded for better outcomes and paid per patient, rather than per visit or procedure) is to increase physician payment rates for primary care services by 50 percent.
- Increase access points: The integration of multiple services (e.g., medical homes) will increase access for some. But we also need to build new brick-and-mortar health centers like FQHC, school-based health centers, rural health clinics, and Indian Health Service facilities.
- Support community-based training programs: Integrated care should become standard training for health professional education programs. Training should take place in community settings and in rural and underserved areas. This will require economic incentives like loan forgiveness and salary supplements.
- Create a primary care research agenda: Much of the research I see in the scientific community draws heavily from subspecialty care, hospital settings, or single-disease cohorts. Primary care research is routinely less than 0.4 percent of NIH’s budget. One place to start is a prioritization of funding at the National Center for Excellence in Primary Care Research office at the Agency for Healthcare Research and Quality.
I encourage readers to cite this report in their own publications and grant applications. We need more stakeholders to see the momentum that is building for major reform in primary care.
“As the United States contends with the effects of the COVID-19 pandemic, health inequity, and a long-overdue reckoning of institutional racism, transforming primary care is essential to meet the moment,” said Victor J. Dzau, president of the National Academy of Medicine. “This report presents an opportunity to reimagine primary care so it reflects people’s needs and values, is supported with the right clinical and financial resources, and remains grounded in equity and social justice.”