Experts criticize HHS efforts to rejuvenate primary care in the U.S.

By Danilo Ezequiel Carando, CNN Week

Updated 12:50 Am December 31, 2023
In an effort to address significant shortcomings in the nation's fragmented healthcare system, the Biden administration recently unveiled plans to strengthen primary care. While some experts commend the initiative for its ambitious goals, others caution that it falls short of resolving the growing crisis in care, which is linked to health disparities, high maternal mortality rates, and a decline in life expectancy.

The report, published by the Department of Health and Human Services in November, outlines steps to change the financial incentives that have hindered access to primary care. It heavily relies on recommendations from the National Academies of Sciences, Engineering, and Medicine, which called for a shift away from the fee-for-service system that rewards physicians for treating illness rather than preventing it.

David B. Nash, a physician and health policy professor at Thomas Jefferson University, praises the report as the best explanation of the problem and what the government can realistically do to address it. However, other experts who closely followed the process view it as a missed opportunity. They note that the report is an "issues brief" released instead of a comprehensive action plan that was promised and would have been coordinated by a centralized leadership team.

HHS declined to explain why the more comprehensive action plan was abandoned but reiterated its commitment to strengthening primary care. Insiders familiar with the process cite months of delays and setbacks, including a breakdown in the leadership structure. Judith Steinberg, a key figure in the leadership team, has retired from federal service and did not respond to requests for comment.

The HHS initiative has ambitious goals but limited financial resources as funding is taken from the agency's existing budget. It aims to address health inequities and ensure that federal programs reach underserved communities. The initiative also intends to improve overall health outcomes by tackling the overdose epidemic and child and adolescent mental health crisis. Additionally, it outlines plans to enhance maternal healthcare and promote collaborations between primary care and public health.

Shantanu Nundy, a primary care physician, asserts that primary care is one of the few interventions proven to improve health outcomes. He criticizes the current system for undervaluing preventive care in favor of costly treatments, resulting in poorer quality of life and shorter lifespans for Americans.

Despite its challenges, some experts believe the initiative is a crucial step toward addressing issues in the nation's healthcare system. One of its goals involves increasing the portion of spending on primary care through the Centers for Medicare and Medicaid Services, which heavily influences the healthcare marketplace. The report also outlines plans to provide additional payments for primary care providers and establish a payment and care delivery model called Making Care Primary in eight states, with the aim of improving access to high-quality care for patients.
Assistant Secretary for Health Rachel Levine, whose career has been in primary care as a pediatrician, did not provide direct comment but praised the effort on the social media platform X, formerly Twitter.
“#PrimaryCare is crucial for enhancing the health and well-being of individuals, families, and communities,” Levine wrote. “@HHSGov, we are investing in numerous initiatives to improve equitable access to comprehensive primary care.”
A new approach
For decades, experts in health systems have advocated for better access to comprehensive, community-based services, partly because the lack of easily accessible entry-level care has been linked to the decline in life expectancy in the United States, making it an outlier among developed nations despite being the wealthiest country in the world.
According to the Centers for Disease Control and Prevention, U.S. life expectancy, which used to be closely tied to a nation's wealth, reached its peak at 78.9 years in 2014 and has since fallen to as low as 76.4 in 2021, returning to levels seen in the mid-1990s. A study published in JAMA Internal Medicine in 2019 found that every 10 additional primary care physicians per 100,000 people was associated with a 51.5-day increase in life expectancy.
Meanwhile, fewer medical students are choosing to specialize in primary care, partly due to the significantly lower pay compared to specialists.
“Medical students see who the heroes and heroines are,” said Nash. “They see that specialists receive all the recognition.”
Robert L. Phillips, co-director of the Center for Professionalism and Value in Health Care and a leader of the National Academies study, expressed satisfaction with seeing the study group's objectives reflected in the federal initiative, although he is uncertain which parts of the original plan HHS will continue to pursue.
“It required a tremendous amount of effort on their part,” said Phillips, who is also a professor of family medicine at Georgetown University. His main concern now is accountability and identifying the person responsible for coordinating the effort and making it successful. Phillips is looking forward to examining the new data-driven Primary Care Dashboard, a tool managed by HHS to monitor the progress of the initiative and guide future actions. HHS stated that the first report from the dashboard should be ready in 2025.
Nundy, the chief health officer of Accolade, a company that offers virtual primary care and mental health services nationwide, and a primary care physician at Neighborhood Health in Northern Virginia, felt that there were significant omissions in the report. He believed that the approach seemed backward-looking at a time when technology, including telehealth, offers the potential to transform healthcare delivery.
“I had the sense that the report was trying to revert to the past, going back to Marcus Welby,” Nundy said, referring to the popular 1970s TV series featuring a beloved family doctor. While that model may still work for some segments of the population, he suggested that others might be better served by community health workers or alternative systems.
“For example, do college students need a full MD or a counselor?” Nundy questioned.
Koller, from the Milbank Memorial Fund, praised the objectives of the HHS initiative but cautioned that the federal government alone cannot bring about the necessary overhaul to make primary care accessible to all.
“This doesn't solely depend on public action. I've been there,” said Koller, a former health insurance commissioner in Rhode Island who collaborated with Phillips on the National Academies report. “You need organized partners outside of government.”
Phillips and other experts also emphasized the need for support from Capitol Hill. In an interview with Washington Post Live prior to the release of the issues brief, HHS Secretary Xavier Becerra stated that the process of strengthening primary care was already underway. “We're making progress,” Becerra said, “but we need our friends in Congress to provide us with the resources to fully realize it.”
In September, Sens. Bernie Sanders (I-Vt.) and Roger Marshall (R-Kan.) introduced a $26 billion legislative bill aimed at expanding primary care and reducing staffing shortages. The impact of that bill is likely to be limited, partly because it is focused almost exclusively on federally qualified health centers, which serve less than 10 percent of the population, while the issues with primary care are much more widespread.
The HHS initiative also fails to address a fundamental flaw in the current financial structure, which relies on a physician visit to initiate the billing process. If a community health worker makes the initial contact, there is no way to reimburse that visit. These problems became more apparent during and after the pandemic, which highlighted the lack of long-term relationships between individuals and their primary care doctors. The challenge lies in finding ways to fund entry-level services and care providers beyond just the family doctor.
"Given the shortages and trust issues, it would be more logical for people to have access to other health professionals first," Nundy said. "The entire system becomes bottlenecked at the physician level."
Meanwhile, family doctors are becoming increasingly scarce, even for individuals with good insurance. Brian Gamborg, a former family doctor in Saskatchewan and Louisiana, where he served as president of the Parish Medical Society and Board of Governors of the State Medical Society, has witnessed the negative impact of private equity, venture capital, and large corporations like CVS and Walmart acquiring primary care companies throughout his four-decade career.
If the HHS initiative manages to attract young doctors to pursue careers in primary care, Gamborg would be pleased. However, he noted, "I retired at the end of June and I can't seem to find a genuine family physician other than my former partners, who are overwhelmed."
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