• In The Trenches

    Carpe Diem: It's Time to Fix Our Broken Health Care System

    "Never let a good crisis go to waste"
    -- Sir Winston Churchill

    As I write this post, the COVID-19 pandemic continues to spread across the country with the number of infected individuals well above 550,000 and the death toll closing in on 22,000. Family physicians continue to step forward to meet the needs of their patients and communities. Many are expanding and modifying their practices to ensure that their patients and communities have access to health care in a setting that protects them from exposure to SARS-CoV-2. Others are moving into full-time inpatient roles as part of workforce surges.

    To each of you, thank you for your service to your patients, your community and the country. The AAFP is proud to work on your behalf and advocate for the amazing work that family physicians are doing.

    Despite the robust response of the physician and health care community, thousands of families are mourning the loss of their loved ones -- family physicians and the family of AAFP staff among them. Others in the family medicine community continue to fight for their lives and defeat the virus, often in isolation. Our thoughts are with the families who have lost loved ones and those who are battling the virus.

    I recently tweeted that COVID-19 has changed health care and primary care. Although this may be well understood at this point in time, the direction our health care system is heading post-pandemic isn't as clear. "Let's chart a new future," I said in that tweet.

    The COVID-19 pandemic will have a devastating impact on our country. Thousands have died, and according to recent projections, thousands more will die during the next several weeks. The pandemic has placed a tremendous strain on our economy and our health care system. It also has provided a clear line of sight into disparities, shortcomings and failures of our current health care system. Issues and policies that were once considered long-term goals are now urgent priorities.

    In the coming months, the country will engage in an important discussion about what happened and how the health care system performed in advance of and during the pandemic. There will be a significant amount of handwringing, finger-pointing and posturing. However, there will also be a window of opportunity to determine how to move forward and what kind of health care system we want and need.

    I have spent much of my professional career envisioning the future of family medicine and primary care and promoting incremental changes aimed at achieving those larger goals. In recent days, I have set aside my focus on incremental achievements toward a better future for family medicine in favor of implementing big, substantive, consequential and disruptive changes.

    There have been moments in history when crisis and tragedy gave way to innovation and investment. In a speech delivered at Harvard University on June 5, 1947, Secretary of State George Marshall laid out a vision for rebuilding post-war Europe. This comprehensive plan would ultimately become the Economic Cooperation Act and, in 1948, would be approved by Congress. Over the course of the next several years, the United States invested more than $13 billion in the rebuilding of the Western European economy. The commitment to something new outlined in the Marshall Plan and the investment by the United States led to a new vision for Europe and contributed to the continent's revitalization.

    We can and should do the same for the United States health care system now. I did not originate the term, but I have been echoing it loudly: We need a Primary Care Marshall Plan -- a plan bold enough to fundamentally change our health care system and consequential enough that the lives of future generations will be impacted by its scope.

    Here is where we should start:

    A Better Health Care System

    Our health care system is largely a top-down model in which the vast majority of spending is allocated to the least-used services. According to Health Affairs, health care spending in 2018 was $3.6 trillion, or $11,172 per person. Now let's look at how that money was distributed on a per capita basis. According to the same article, physician and clinical services represented about 20% of overall health care spending, or $2,234 per person. Hospital spending represented 33% of overall spending, or $3,687 per person. By my (generous) estimation, primary care represents about 5% of overall spending, or $559 per person.

    Now, let's look at utilization. According to statistics from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care for 2018, a little less than 22 million people -- about 7% of the population -- received care in a hospital compared to the more than 190 million people -- roughly 60% of the population -- who received care from a family physician. I am not suggesting that family physicians need to be paid on par with hospitals and I am not necessarily saying that hospitals need to be paid less. What I am stating is that an overwhelming majority of people rely on their family physicians and other primary care clinicians, yet we invest only pennies on the dollar in our primary care system.

    This, my friends, is an opportunity for change. Here is how we are going to capitalize on the opportunity:

    Prospective Population-Based Payments for Primary Care

    I am going to state clearly and loudly that fee-for-service is incapable of supporting the primary care system that our health care system needs and that patients deserve. The whole construct of FFS, and especially the resource-based relative value system, has failed primary care. Primary care is comprehensive, continuous, holistic, portable and patient-centered. The RBRVS is, by design, the complete opposite. It is focused on units of care, units of time and sites of service. Family medicine has politely whispered for years that FFS was an illogical payment construct for primary care, and the COVID-19 pandemic simply put a giant spotlight on this issue.

    The concept of prospective payments is not new. The AAFP has advocated adopting this type of payment model for years and, in 2018, we developed the Advanced Primary Care Alternative Payment Model. Our model is the foundation of the Primary Care First model that CMS will implement in 2021. We also have advocated for other global/prospective value-based payment models, such as direct contracting, physician-led accountable care organizations and direct primary care arrangements. Although it is easy to focus on what makes these models different, it is more important to focus on what makes them similar: They all depend on population-based, advance payment for primary care.

    In response to the COVID-19 crisis, public and private payers alike have altered benefit design and begun making advance payments to family physicians. We should build on this momentum and once and for all make a complete break from the legacy fee-for-service system.

    The pandemic has brought to light how inflexible and unresponsive our health care system has become. It took us three weeks to create a pathway for family physicians to provide and be compensated for virtual care visits via telemedicine or the telephone. This is because we currently pay for units of care and units of time, and our regulatory structure is designed accordingly. Imagine if every family physician had had an attributed panel of patients and an associated prospective payment for each when the crisis hit. Transformation from office-based to virtual workflows would have been easier and quicker. Home visits? Fine. Telephone visits? Fine. A game of virtual checkers with Ms. Smith because she is isolated and gets lonely? Fine. When units of care and units of time no longer get measured, providing care to patients becomes the focal point. And, when providing care to patients is the focal point, family medicine wins.

    The Primary Care Marshall Plan is underway. There are countless other aspects of health care that should and will be included -- the family medicine workforce, comprehensiveness, continuity, public health training, and infrastructure and analytics -- all in time. Today, the two items I outlined deserve our full attention and support. They are the foundation.

    Again, let's chart a new future. Our future.

    Shawn Martin is senior vice president of advocacy, practice advancement and policy.


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