Nina, the mother of an autistic teenager, had never experienced a panic attack until Covid-19 closed her son’s school in March 2020. Then they began coming with alarming regularity. Single parenting a disoriented child she couldn’t leave unattended meant she had to quit her job and was homebound, with no one to help with necessities like food shopping.
In desperation, Nina (not her real name) called a local clinic, and was lucky to find one with a corps of clinicians, counselors, and social workers using a model of primary care that integrates services to support physical, mental, and social well-being. They rapidly assessed her and her home situation via telehealth, explained and normalized her symptoms, prescribed medication, and gave a warm hand-off to mental health counselors. They also arranged deliveries from community food banks and helped her apply for unemployment benefits. The clinic became her lifeline, giving Nina and her son life-saving physical, mental, and social support through a year of isolation until schools reopened.
For years, many primary care practices have stepped up to address the multiple health crises roiling communities across America — a surge in mental illness that behavioral health providers cannot absorb, a rise in addiction, persistent strains on rural health care, and the health effects of social stressors especially for people of color and those with low incomes, or disabilities. Covid exacerbated these interrelated crises. Economic stress contributes to higher rates of anxiety, depression, suicidality, substance abuse, and addiction. As rural hospitals and clinics close, lack of access to trusted health care providers deprives these and other disadvantaged communities of another important layer in the social safety net and increases the risk of poor health and life outcomes. The pandemic has made clearer than ever the vital roles that primary care plays.
The resilience of primary care cannot be taken for granted. Signs abound of the strain on many practices under current financing and payment arrangements. Primary care lost an estimated $15 billion in 2020 and, a year later, fully one-third of practices reported not having recovered financially. As a result, a growing number of once-independent practices have been acquired by hospitals or private equity firms.
But even before the pandemic, primary care was already struggling under fee-for-service systems. A clinical team needs time to provide psychological support, understand a person’s social context, and tailor outreach to appropriate community groups and agencies to truly solve a patient’s problem. Taking time to fully understand a patient’s problems and tailoring actions to solve those problems are “lumpy” and unpredictable demands in a clinician’s day that are antithetical to fee-for-service payment. America’s reliance on primary care and expectations for it keep growing, but the country’s investment in it has not kept up.
A meaningful step forward would be to empower primary care with flexible, adequate payments and technology so all practices can integrate physical, mental, and social supports, and partner with other service sectors. The integrated model of care that Nina was fortunate enough to find is not widely available, precisely because current payment structures and chronic underpayment for primary care create insurmountable barriers to incorporating behavioral health and social supports for most practices. Federally qualified health centers that can offer integrated care often rely on cost-based reimbursement to build this infrastructure. The Veterans Administration’s whole health model similarly relies on predictable annual budgets and salaried staff. Paying for collaborative psychiatric care, as Medicare is now doing, is a start. A better way would be to convert a substantial portion of primary care payment to periodic and predictable lump sum payments. That would free practices from chasing more visits and more billings and allow them to focus on the patients in front of them.
A multi-disciplinary team, telehealth, e-consults, home-monitoring tools, connections to and relationships with community-based service partners, and peer-to-peer support from specialist colleagues can form a chassis that gives primary care providers the resources and capabilities they need. But few practices, especially those serving rural or minority or low-income communities, can afford to make these investments on their own. National investment in teams and tools, whether from public or private insurers, could be a much more effective expenditure than paying for the downstream costs and health burdens of neglecting to provide truly whole-person care.
It is possible to rebuild this necessary backbone of the U.S. health care system with a combination of these up-front investments and then offering primary care providers a sustainable business model through value-based payment programs that have already shown success by rewarding high quality and contained spending.
Based on experience in other countries and comparisons of different U.S. communities, investments in primary care would pay for themselves over time in reduced total health care spending from fewer specialty and hospital services, and reduced health burdens that lead to lost work productivity and lost years of life. A broad and growing coalition of stakeholders is coming together to advance a policy agenda for reforming primary care payment, based on recommendations from the National Academies of Science, Engineering, and Medicine (NASEM). Rural providers, mental health advocates, safety net clinics and health systems, primary care practices, payers, employers, and consumer advocates all understand that they cannot afford not to act. The Centers for Medicare & Medicaid Services has offered various pilot payment programs for primary care, but none with the duration or degree of investment recommended by NASEM that can be scaled across the country.
The Biden administration and Congress should support what the evidence shows: primary care is the only part of the U.S. health care system that, with additional investment, will improve population health across all communities.
Hoangmai Pham is the president and chief executive officer of the Institute for Exceptional Care and former chief innovation officer for the Center for Medicare and Medicaid Innovation. Michael O. Leavitt is the founder and chair of the Board of Managers for Leavitt Partners, an HMA Company, and cochair of HMA. He is also the former governor of Utah, and former Secretary of the Department of Health and Human Services.
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