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COVID 19 Affect on the Health Care System

Is There a Future for
Primary Care?
invest in a moonshot to achieve equity
or large-scale community development
initiatives, we must leverage existing
resources within health care, the largest
sector in the US economy, and incrementally redirect resources toward an
William J. Kassler, MD, MPH
integrated response.
There is an emerging consensus
among policymakers that true health
William J. Kassler is with IBM Watson Health, Cambridge, MA.
See also Benjamin, p. 542, and Fine, p. 608.
improvement can only be achieved by
addressing the underlying causes of
poor health. Public health and human
services practitioners are trained to
April 2021, Vol 111, No. 4
s we reflect on the stunning suc-
shortages, the emergence of concierge
think upstream to identify and address
cess of applied biomedical re-
and direct care models, the proliferation
the root causes of poor health. But so-
search in developing a SARS-CoV-2
of retail convenient care clinics, and the
cial determinants also resonate with
vaccine less than a year from the virus’s
emergence of direct-to-consumer tele-
primary care clinicians who see firsthand
emergence, we are also sobered by how
health platforms. As we look to a post-
the role of environmental, behavioral,
quickly the pandemic overwhelmed our
pandemic world, will our current primary
and social factors in the health of their
capacity to take care of sick people and
care system be up to the task of im-
patients. Many health care providers
how public health departments have
proving population health outcomes
realize that they must deal with a pa-
struggled to respond at scale with core
and addressing health disparities in an
tient’s most pressing issues, whether
disease control strategies such as test-
impactful way?
that is abnormal glucose, or eviction,
ing and contract tracing. The COVID-19
or racism. There can be real power in
pandemic has shown us the existing
population health outcomes and re-
aligning primary care with public health,
weakness in our clinical systems and
ducing disparities has been extensively
social services, and population-based
highlights the fragile state of our public
documented.2 However, to make a dif-
approaches within communities.
health infrastructure. COVID has also
ference at the population level, more
revealed preexisting social inequities
needs to be done and at a larger scale.
that have led to shocking disparities in
Given how little clinical care contributes
health outcomes. Public health, primary
to the health of a population,3 does it
Catalyzed by the Centers for Medicare
care, and equity have emerged as three
make sense to continue to focus scarce
and Medicaid Services (CMS) Innovation
key themes in the pandemic, and
resources on a population’s medical
Center and other innovative payers, we
aligning the efforts of public health with
needs rather than on social needs such
are seeing a growing effort to pay for
primary care and with community-based
as early childhood education, nutrition,
population services delivered in clinical
organizations should be a major part of
and housing? If we were to de novo
settings and pass resources through
our efforts to emerge from this disaster
design the ideal health system, the an-
health care systems to engage and le-
swer is likely not. Medicine would be
verage community-based organiza-
In the highly competitive Hobbesian
optimally designed for the care of sick
tions.4 While alternative payment
marketplace of health care, neither pri-
individuals, social and human services
models are intended to hold health care
mary care nor public health are large
providers would attend to individual
systems accountable for population
revenue sources and, thus, they are
social needs, and public health would
outcomes, early results have been
chronically underfunded. Primary care is
look to population-level interventions.
struggling within an economic system
Yet, in this current economic climate, it is
that values procedural and specialty
unlikely that significant new funding will
financial incentives and focusing on
care over cognitive and preventive care.
be appropriated to address systematic
practice transformation, primary care
It is being squeezed by workforce
social needs. Absent the political will to
practices can improve quality, focus on
The value of primary care in improving
There is evidence that by providing
prevention, and better coordinate care
based psychosocial services and en-
similar infrastructure to understand lo-
for patients with complex psychosocial
hanced access to care, and explicitly
cal epidemiology, assess community
needs. But only a small proportion of
address social needs via case manage-
health needs, measure disparities, and
US primary care practices are certified
ment, translation, and transportation.
effectively target resources to address
as primary care medical homes, and
To assure a community-driven collabo-
both gaps in care for individuals and
their results have been of insufficient
rative approach, the majority of FQHCs’
outreach to critical underserved
magnitude to improve outcomes for
governing boards are community resi-
populations. Three large-scale demon-
dents and patients of the health center.
strations by the CMS have shown limited
With recent funding from the Affordable
impact on cost, quality, or patient
Care Act, community health centers
have seen significant expansion.
A second model worth noting is the
COVID-19 has exposed the deep faults
in our health care and public health
systems. Public health has been chal-
By aligning clinical and community
lenged to control the outbreak, manage
To be relevant, primary care needs to
partners and embracing shared re-
the surge, maintain core services, and
reinvent itself and accelerate the types
sponsibility for population health out-
balance the competing needs of pro-
of transformative changes alternative
comes, AHCs bring together providers,
tecting health and opening up the
payment models hoped to catalyze.
payers, businesses, and governmental
economy. Similarly, primary care is
Looking back to the 1960s’ Community-
health and human services agencies.
struggling to meet the needs of patients
Oriented Primary Care Movement may
These nascent multisectoral collabora-
during the pandemic.
show us the way forward. This blended
tions hold promise, but like the FQHC
model of primary care and community
model, require a primary care system
the surface, it may seem daunting to
public health not only treats individuals
capable of expanding beyond sick care.
reconcile individual and population per-
who present for medical care but also
For primary care to substantively con-
spectives within the two balkanized and
assumes responsibility for such public
tribute to population health gains, it
underresourced systems. But the plan-
health activities as conducting basic
must incorporate an integrated ap-
ned integration of public health practice
epidemiological surveys and plan
proach to social determinants.10 The
with the delivery of primary care services
ning and implementing community
primary care model of the future must
is needed precisely because neither of
interventions—all in collaboration with
look more like an FQHC or AHC than the
these sectors can do it alone. Engaging
idealized Marcus Welby practices of the
with the community is the third practice
last century.
necessary to achieve equity. Low-income
Perhaps the best example of
community-oriented primary care in the
Primary care needs to move from a
One way forward is to align efforts. On
April 2021, Vol 111, No. 4
local authorities.
Accountable Health Community (AHC).
and minority groups face barriers to
United States is the extensive network
physician-centric to a multidisciplinary
accessing primary care in part because of
of federally qualified health centers
team in which care is primarily delivered
affordability and additionally because of
(FQHCs), which provide comprehensive
by other members of the team. True
systemic racism. Without including un-
primary care and preventive services to
integrated care requires an expanded
derrepresented and marginalized groups
all residents in their service area, re-
workforce of social workers, care coor-
in the decision-making process, there will
gardless of ability to pay. Established in
dinators, nutritionists, behavioral health
be no confidence in the policies and
1964, the community health center
providers, community health workers,
programs to reduce disparities.
model was explicitly developed to target
and others. Primary care must also
the underlying issues of poverty and
embrace technology, data, and analytics.
be a once-in-a-generation opportunity
equity by combining the resources of
Health care delivery systems have
to engage in a broad dialogue about
local communities with federal funds to
invested in health information technol-
the value of public health and primary
establish neighborhood clinics in both
ogies to manage their operational
care, and the type of system we want
rural and urban underserved areas.
complexities and improve accountability
to build to meet the essential challenge
FQHCs provide robust primary care but
to payers for cost and quality. An inte-
of our times—how to achieve health
also include referrals to community-
grated primary care practice must have
for all.
Looking toward recovery, this may
Correspondence should be sent to William
J. Kassler, IBM Watson Health, 75 Binney St, Cambridge, MA 02142 (e-mail: w.kassler@ibm.com).
Reprints can be ordered at http://www.ajph.org by
clicking the “Reprints” link.
Full Citation: Kassler WJ. Is there a future for primary
care? Am J Public Health. 2021;111(4):606–608.
Acceptance Date: January 15, 2021.
DOI: https://doi.org/10.2105/AJPH.2021.306181
The author wishes to thank Jack Westfall, MD, MPH,
of the Robert Graham Center for Policy Studies in
Primary Care and Family Medicine, for his thoughtful
review and helpful comments.
2. Starfield B, Shi L, Macinko J. Contributions of
primary care to health systems and health. Milbank
Q. 2005;83(3):457–502. https://doi.org/10.1111/j.
3. McGovern L. The relative contribution of multiple
determinants to health outcomes. Health Affairs
Health Policy Brief. August 21, 2014. https://doi.org/
4. Kassler WJ, Tomoyasu N, Conway PH.
Beyond a traditional payer—CMS’s role in
improving population health. N Engl J Med.
2015;372(2):109–111. https://doi.org/10.1056/
5. Cotton P. Patient-centered medical home evidence
increases with time. Health Affairs Blog. September
10, 2018. https://10.1377/hblog20180905.807827
6. RTI International. Evaluation of the multi-payer
advanced primary care practice (MAPCP)
demonstration final report. June 2017. Available
Primary Care Is Dead.
Long Live Primary Care
7. Kahn K, Timbie JW, Friedberg MW, et al.
Evaluation of CMS’s federally qualified health
center (FQHC) advanced primary care practice
(APCP) demonstration final report. 2017. Available
at: https://www.rand.org/pubs/research_reports/
RR886z2.html. Accessed December 21, 2020.
8. Mathematica Policy Research. Evaluation of the
Comprehensive Primary Care Initiative Fourth
Annual Report. May 2018. Available at: https://
downloads.cms.gov/files/cmmi/CPC-initiativefourth-annual-report.pdf. Accessed December 21,
9. Mullan F, Epstein L. Community-oriented primary
care: new relevance in a changing world. Am J Public
Health. 2002;92(11):1748–1755. https://doi.org/10.
10. National Academies of Sciences, Engineering, and
Medicine. Integrating Social Care into the Delivery
of Health Care: Moving Upstream to Improve the
Nation’s Health. Washington, DC: The National
Academies Press; 2019. https://doi.org/10.17226/
insurance companies, their employers, and their electronic medical
record systems—quit when the pandemic hit. Many more are burned out
and disheartened. 7
Michael Fine, MD
And few primary care practices have
realized their potential in protecting
April 2021, Vol 111, No. 4
The author has no conflicts of interest to disclose.
1. Westfall JM, Petterson S, Rhee K, et al. A new “PPE”
for a thriving community: public health, primary
care, health equity. Health Affairs Blog. September
25, 2020. https://doi.org/10.1377/hblog20200922.
at: https://downloads.cms.gov/files/cmmi/mapcpfinalevalrpt.pdf. Accessed December 21, 2020.
the public’s health. Too tired or timid
Michael Fine is with City of Central Falls, Rhode Island.
to resist third-party demands, too individualistic to organize, and too restrained
See also Benjamin, p. 542, and Kassler, p. 606.
by the golden handcuffs of a business
model that stopped serving the public
assler is correct, of course (p. 606).
before the pandemic. 4 The market
years ago, primary care clinicians failed to
The nation would be well served if
share and population health impact of
make care accessible to people when and
we provided robust primary care to all
primary care is falling. 5,6 The pan-
how they needed it and failed to think
Americans. The association between
demic caused most primary care
about the health of the populations they
practices to move the bulk of their
purport to serve, providing
primary care supply, public health outcomes, and lower costs is well known.
“encounters” to telephonic care, a
Primary care practices and clinicians are
change that fractured primary care
also well positioned to bear witness to
relationships, replacing the intimacy
the impact of social determinants on
of the primary care bond with a phone
population health and to help fire the
or video call between a person and a
mobilization needed to change that.
“provider” who could be miles away
too few options for same-day care;
too little use of telephonic care when
that was actually appropriate;
too little integration of mental and
behavioral health, use of community
and not necessarily a part of the
health workers, physical therapy and
trouble for years, trouble that only
person’s community. Many primary
other functionally focused modali-
deepened during the pandemic. Only
care clinicians, already weary of
ties; and
about 45% of US adults had a mean-
“strangers at the bedside”—Centers
ingful primary care relationship
for Medicare and Medicaid Services,
But primary care has been deep
far too little building of enough capacity to serve entire communities.
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