Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep146: The primary care crisis, by the numbers, with experts from the Milbank Memorial Fund, the Physicians Foundation and the Robert Graham Center
Transcript
- 0:00 Physicians face challenges every day, from difficult patient encounters to changing regulatory requirements at Copic, our commitment to you goes beyond providing reliable medical liability insurance. What sets us apart is our proactive approach, a 24/7 hotline answered by physicians, specialty specific guidance and CME accredited education and unwavering dedication to help you thrive, C, o, p, i, c, com, we're Copic here for the humans of health care here for you. 0:28 There are a lot of people out there who might say that, you know, America's health care system is broken, and what I would say is is not really broken at all. It's just off balance. Welcome 0:41 to off the 0:51 chart, a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the associate editor of medical economics, and I'd like to thank you for joining us today. In today's episode medical economics, senior editor Richard perryton sat down with four experts to talk about a report released earlier this year investing in primary care, the missing strategy in America's fight against chronic disease, published jointly by the Millbank Memorial Fund, the physicians Foundation and the Robert Graham Center. The report makes the case that primary care is both the most powerful and the most underused tool the US has in its fight against chronic disease, and the country is paying the price for under investing 1:29 in it. You'll hear 1:30 from Dr Morgan McDonald, a national director for population health the MOBA Memorial Fund. Debra Lubar, the president of the mobac Memorial Fund, Dr Ripley Hollister, a family physician and board member of the physicians foundation and Dr Yalda job report, a family physician, lead author of the report, and Vice President and Director of the Robert Graham Center. Thank you to all of our guests for joining us today, and now let's get into the episode. 1:54 I'm Richard 2:01 payer chin reporting for medical economics. With me today is Dr Morgan McDonald, 2:06 Richard, thank you so much for having us. We really appreciate 2:09 it. Deborah Lubar, 2:10 thanks for having me, 2:11 Richard. Dr Ripley Hollister, 2:13 thank you, Richard. Pleasure to be with you 2:14 and Dr Yalda job report, 2:16 thank you for having me to 2:18 start. Richard asked each of the guests the same opening question 2:21 in your own words, how would you describe the state of primary care in the United States today? 2:26 I think the state of primary care is that we are suffering and need more support in order to really support the care of all patients in the US. 2:37 I think it's strained and somewhat threatened by the cost of risk that's happening in other parts of the system, and that's why we wanted to do this report to really highlight particularly if we want the health outcomes that we all want for our families, we don't we want to prevent chronic disease for our family members who have chronic disease, we want them to manage that well, so that they can live their fullest lives. And we want longer, healthier lives for everybody. And primary care is is the front door to that, and in many ways, it's the backbone to that. 3:12 So I think most primary care clinicians, myself included, would probably use the word threatened. So despite all the rewards of practicing in primary care, inadequate reimbursement from insurers, combined with increasing numbers of patients with chronic disease, mental health and social needs like housing or food insecurity, as well as those growing mounds of paperwork and documentation really combined to overburden primary care clinicians, 3:39 and that burden has consequences. Only one in five physician trainees is currently choosing primary care, and the report found that nearly a third of us, adults and 12% of children go without a usual source of primary 3:50 care. And the report notes growing costs of health care for chronic conditions and cancer. It also cited the Make America healthy again agenda with a shift toward preventing chronic disease, or at least slowing its progression. Why is primary care the specialty best positioned to lead this shift? 4:08 Prevention is nothing new for primary care. It is the cornerstone of primary care. We are the specialty that is in charge of prevention. We like to see patients before they have a disease. There's probably no other specialty that wants to see patients before they have a disease. Our job is to prevent patients from getting that disease, whether it's through immunizations, whether it's through counseling on things like diet and nutrition, counseling on things like smoking, whether it's doing those really essential screenings of your blood pressure, your lab work like your cholesterol, or for the most common cancers that plague Americans, primary care has always done that. It's nothing new for us, and we just wanted to highlight how important we. Are to the agenda of making America healthy again. 5:04 Primary Care is both the front door medicine as well as the backbone of good health in a community. Its focus, as we know, is on prevention and routine ongoing care that really is essential to lead the effort to better prevent and manage chronic disease. This reports emphasis, in particular on a regular source of care also highlights the importance of having that clinician patient relationship, and that's something that I know that I value the most in my primary care practices, those relationships, and that bears out when really in health outcomes. And so every study done today re emphasizes a person's usual clinician is their most trusted resource for health related decisions, and also impacts their community as well. We've seen in recent data that for every 10 additional primary care clinicians per 1000 people, life expectancy. Life expectancy at the county level actually increases. The report 6:04 looked 6:04 at Medical Expenditure Panel Survey data from 2016 to 2022 six years of national data tracking what happens to people who have a primary care physician versus those who don't. It also looked at Medicare Fee for Service claims to examine what continuity of care does for patients who already have a chronic disease. Adults with the usual source of primary care were nearly 28 percentage points. Percentage points more likely to have their blood pressure checked, 33 percentage points more likely to have cholesterol screening, and nearly 30 percentage points more likely to get a mammogram compared with those without a primary care physician. We asked Dr job report to walk us 6:35 through that finding, compared to not having a primary care physician, patients who have a primary care physician were more likely to get screening for one of the biggest killers in the nation, which is cardiovascular disease. They were also more likely to get their cancer screening done, which is interesting, if you think about it, because the cardiovascular disease screening happens when you're in your primary care doctor's office, you don't have to make an extra visit for that. But the cancer screening, these are things like mammograms, colon cancer screening, these don't actually happen in the primary care office. You see your primary care physician, you get counseling on it. They give you a referral to go get that the fact that that completion was higher for people who had a primary care physician than those that didn't. Was a little bit surprising, because it takes an extra step, right? And that just speaks to the trust that is developed when you have a primary care physician, the importance of that relationship to say, Hey, I know it's one more step. This is really important to your health. And on the patient side to say, Okay, Dr J really wants me to do this. You know, we've had this long term relationship. I'm going to get this done, whether it's for me or for her. I think is really important. And you really, we really try to highlight that that is one of the important things about having a continuous relationship with a primary care physician. For children, 8:01 the findings were even more pronounced. Kids with the usual source of primary care were more than 50 percentage points more likely to receive vision screening and significantly more likely to receive counseling on obesity prevention, injury prevention and secondhand smoke exposure. For children who already had a chronic condition, having a primary care physician cut their odds of an avoidable emergency department visit or hospitalization by nearly 50% 8:22 children who have a usual source of primary care lower their odds of going to the emergency department or being hospitalized for a condition that could be treated in an outpatient setting by about 50% so these, these are big numbers. I mean, you talk about going to the emergency room. You talk about imaging, CAT scans, MRIs, various things, preventing that and taking care of it, and then different setting, you get much more continuity, better, better exposure and usefulness going forward and prevention of advancement of this chronic illness. And 8:59 Dr job before argues that pediatric data matters beyond the immediate health picture because of what childhood habits become. 9:05 I think if we're going to keep the US population healthy, it actually starts with our care of children, right? The the long term habits that we have as adults start in childhood, and whether those habits are you know, what we eat, how much we exercise, or whether those habits are making sure that I'm seeing the doctor yearly for immunizations and screenings. That all starts in childhood. So I would argue that the findings that we have for the pediatric population are probably the most important findings in the report. And I think as those children grow, you know, those habits that are instilled in childhood will follow them into adulthood. And so if we can start with children, we can make the entire population more healthy in the future for any 9:56 practice leader or physician dealing with the financial realities of medicine and. Day. Here's the number that stopped everyone when the report came out, adults with chronic disease who had a usual source of primary care had nearly 54% lower total healthcare expenditures than those without one. For children with chronic disease, it was nearly 40% 10:12 lower. What was the finding that was most surprising to you? 10:15 The thing that really surprised me coming out of this report was the impact on cost. I knew that we as primary care clinicians were saving the system, so to speak, money. I didn't know how much. And so when you look at adults with chronic disease who have a usual source of care, those health care costs are lowered by almost 50% that's a huge overall cost savings. So I'm just going to say that again, adults with chronic disease who have a usual source of care, primary care, lower their overall health care costs by 50% and so that really tells us that we should be investing more in primary care as an overall cost saving strategy for the health care system. 10:58 To me, the most surprising finding was that that people with a usual source of primary care had nearly 54% lower health care costs. That's been a really hard thing to quantify, and this is one study, but we're seeing other studies that are verifying this. And I think there's been this belief that, you know, primary care is a good investment because of the health outcomes. And at Milbank, we definitely believe that. And you know, there are some audiences where they really want to say, Okay, well, how could we finance that? What are where? Where would that money come from? And I think increasingly we're starting to see that there are actual savings. Now, you know, the timeline for those and whose money gets saved is something that affects policy solutions that can be used there, but I think it's a that was a surprisingly large savings, and you know, adding to that body of evidence that primary care saves money over the long term 11:57 for adults who Have a usual source of primary care who have a chronic illness, they have a reduction in total health care expenditures of nearly 54% I mean, that is huge. And I got to tell you, that's a little surprising to me. That's a big number. So having having that usual source of care, it reduces their odds of going to the emergency room by about 11% it reduces their risk of hospitalization by a good 20% so those, those numbers, I think, were somewhat surprising to me. I really did not realize they would be that huge. 12:36 Okay, so quick recap, primary care is preventing disease, reducing hospitalizations and driving down total health care costs, but we're spending less than 5% of total US health care expenditures on it, and that number has been a consistent finding for years. We asked whether anything's 12:49 changed. Unfortunately, not, you know, and I know things don't change quickly, right? When we're talking about what proportion of total health care spend is spent on primary care, that's not going to change quickly that actual number. What we have seen change, though, is that states really are taking the initiative to at least start measuring how much the payers in their state are spending on primary care. You've got to start with measurement right to know what your benchmark is. And then some states have really taken the initiative to say, Okay, we're maybe starting at 5% or 6% we want to double that in the next X amount of years. 13:29 Ideally, we'd love to see that double we published a work by Dr ASAF baton back in November. He's the Executive Director of Ariadne Labs, which does a lot of this. We partner a lot with with their primary care research. I mean, he called for a doubling of primary care spend, so that 5% number we noted a minute ago to increase that to 10% of total health care expenditures by 2030 and I think that's a great rallying cry for primary care across the country. That would put us much more in line with peer health systems that spend a whole lot less overall on health care, but see better outcomes. 14:06 But this 14:07 isn't just about spending more money, it's about spending it differently. The way primary care is currently paid for, which is primarily fee for service, doesn't always capture what primary care actually does 14:17 when I say investing more and differently in primary care. I mean, we need to increase our investment and move it away from a fee for service system a transactional system, because primary care is not a transactional model of care. So when you are just paying for visits that happen inside the office, you're actually not You're not reimbursing for the entire breadth of what a primary care clinician does, which really is population health. Some of that happens within the confines of the office in a visit, some of that is happening after. Hours. A lot of that is happening after hours. It's happening via the phone. It's happening via patient portals. It's happening, you know, in a variety of different ways. And it's not only the doctor that's doing it, it's the entire office. Dr Ripley Hollister 15:14 flagged a specific policy mechanism that points toward what a better funded primary care system could actually look like. Medicare's advanced primary care management codes added to the physician fee schedule in 2025 provide a monthly per patient payment for coordinating ongoing care. 15:27 One of the ways would be to to have Medicare basically pay more for primary care and pay for it differently and included in in that would be to look at primary care as a preventative service, if you will, everything that goes on. The pride in the primary care field can be, as we're talking about, geared towards, towards this prevention of either worsening of illness or of illness altogether. Medicare pays for preventative services like preventative colonoscopy, for example. As you probably know, they pay for that 100% so patients are really encouraged to use these services, rather than having to deal with the deductibles and co pays and things like that. And if Medicare would would improve that investment and look at primary care services is largely preventative, that would really open the the floodgates, if you will, for primary care practices to survive. You know they're they're dwindling as we speak. 16:37 Hey there. Keith Reynolds here and welcome to the p2 management minute in just 60 seconds, we deliver proven, real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow, hack an employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at K Reynolds at mjh life sciences.com with your topic. Quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute. The 17:27 spending gap doesn't exist in isolation. It's part of a cycle that's actively shrinking the primary care workforce at exactly the moment that the country needs it to grow. 17:35 It's why primary care clinicians are retiring early or leaving clinical care altogether at a young age is because they are overburdened and under resourced. And so if we want to make it so that you know, a third of people in the United States who don't have a primary care clinician right now can get that primary care clinician? We really need to think long and hard about how we're spending healthcare dollars and why we aren't spending more on primary care for physicians in 18:13 independent practice who have fewer administrative resources and thinner margins than large systems. The weight of all this falls harder. Dr Hollis serve on to five clinician practice in Colorado Springs. So we asked him about the staffing realities on the ground 18:25 currently in my clinic. I think if you look at my staffing roughly, it takes probably five staff members to take care of one one full time clinician, if you will. So that's pretty high and maintaining, maintaining the staff, I think, is is always been difficult. But ever since covid, it's it's been nearly impossible to to have enough staff to to take care of your medical assistance, front office, receptionist, things of that nature, trying to hang on to these people and maintain them as employees had been quite difficult. 19:05 Dr McDonald tied the workforce problem back to where physicians are trained in the first 19:09 place. The vast majority of physician training now happens in academic medical centers, which are driven by those RV use, which is specialist based, and so that tends to be the pathway. So more than 80% of physicians wind up as specialist physicians because they see the payment. So, you know, higher paycheck coming into specialists, and also they're not training in an environment where they see really high quality primary care. When we see investments in things like teaching health centers, those are community health centers that have a residency component, much higher percentage of those trainees go into primary care. They really see it as the tool to better health. 19:58 And 19:58 there's a role for employers in this course. Equation two, the report specifically recommends that large employers purchase health plans that promote access to usual source of primary care. 20:06 And as an employer, I would be shopping around for those plans. I would look for plans that have, you know, the best access to good primary care. I know a lot of times we're looking for great access to, you know, the number one hospital in the in the area, or, you know, the best pharmacy choice or pharmaceutical choices, or the best access to the top specialists in the area. But really, if the employer is looking to save money make sure that their employees are healthy. They really should be negotiating with plans that have great Primary Care Access and plans that make sure that they are adequately reimbursing their primary care offices to deliver high quality care. The report 20:59 closes with seven specific recommendations covering Medicare payment, Medicaid reform, graduate medical education and more. We asked each guest the same closing question. 21:09 The report has seven recommendations to improve primary care, if you could turn the switch on tomorrow, so to speak, to make one of those happen. Which one would you select to have the greatest effect on American health 21:20 care, 21:21 what we would really want to see is on an increase in that so ongoing, increasing value reimbursement for for primary care, but for Medicaid and commercial payers to go along with that. So we like we because we give so much value to the system to be able to pay for a value based structure that really incentivizes primary care. It's a lower cost of care giving primary care practices a real financial underpinning to be able to do the things that they need to do to increase access. And then if Medicaid could pay at the same rate, if commercial payers could pay that or more, as they often have additional revenues there, we would see really transformational change within a primary care practice, to be able to again deploy teams in a team based environment, and to increase access for patients, and ultimately to to incentivize and draw new new residents and physician associates and nurse practitioners into the field of primary care, because it's the best place to practice 22:34 the policy solutions that help us Balance and more robustly fund the prevention part of our health care system, the primary care part of our health care system, I think are the most important policy tools that's going to that's going to help with recruiting clinicians into primary care. It's going to help with improving access to primary care, and it's it's going to give us a healthcare system that aligns with our values around prevention and promoting health. 23:06 Oh, I mean, I think this all starts with financing. So it would have to be something around increasing how much we're investing in primary care. And when I say that, I'm not talking about paying doctors more. I mean, of course, you know, compared to other specialties in medicine, primary care is reimbursed the least, but it's not about the take home pay of doctors. When I say investing more and differently in primary care, I mean we need to increase our investment and move it away from a fee for service system a transactional system, because primary care is not a transactional model of care. We 23:46 spent this episode talking about systems, policy, data, but the report is at its core about the relationship between a physician and a patient, what that relationship prevents, what it costs when it doesn't exist, and what it's worth fighting to protect. Our main audience is primary care physicians. What would you like to say to them? Or what would you like them to know? 24:04 Well, I'd like to say to them that you know we see you and we see the value, and we want to raise that up along with your care team members, so that you can do the job you train to do and be the trusted source of care in your communities. 24:23 And Dr jobpapore, who wrote the report and still sees patients, offered this to any physician who has ever felt like no one outside the exam room understands what they're up against. 24:31 Sometimes it can feel lonely working in your office, feeling like no one is fighting for you, no one is doing anything for you. You know you're stuck with all this administrative burden, this burnout, you're in charge of taking care of this entire population. And I think you know reading about some of the things that you know we are trying to get movement on at a federal or state level can be somewhat reassuring for the practicing primary care physician. The 24:58 full report investing in. Primary Care, the missing strategy in America's fighting as chronic disease is available through the Millbank Memorial Fund website@milbank.org and is linked in the show notes. Once again, our guests, Dr Morgan McDonald, national director for population health at the Millbank Memorial Fund. Deborah Lubar, president of the Millbank Memorial Fund. Dr Ripley Hollister, a family physician and board member of the physicians Foundation. And Dr Yada jabopoor, Vice President and Director of the Robert Graham Center and lead author of the report, also speaking with medical economics senior editor Richard Harrison on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories and solutions for your practice. You can find us by searching off the chart, wherever you get your podcasts, and if you'd like the best stories that medical economics and physicians practice published delivered straight to your email six days of the week, subscribe to our newsletters at medical economics.com and physicians practice.com off the chart, a business of medicine podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Latrell, medical economics and physicians practice are both members of the mjh Life Sciences family. Thank you. 26:20 You.