Prioritizing Primary Care

Research shows the more that is invested in primary care, the better health outcomes will be.

November 2022 – The Journal of Healthcare Contracting

As director of the Robert Graham Center – part of the research division of the American Academy of Family Physicians (AAFP) – Dr. Yalda Jabbarpour fields a lot of questions from primary care doctors. For instance, during the rollout of the COVID-19 vaccine, she was hearing a lot of the same questions: “Why aren’t primary care doctors getting more of the vaccine? We thought primary care offices were the people who traditionally vaccinated the public rather than retail clinics or the hospitals.”

“We said, ‘Yes, anecdotally you feel that. But let’s look at the research.’”

So Dr. Jabbarpour and her team looked at the research on past vaccinations and found that their hypothesis was actually true – the majority of the vaccines that were given in the United States have been given in the primary care office.

“That data was instrumental in helping the AAFP and family physicians advocate for getting COVID-19 vaccines into the hands of primary care physicians,” said Dr. Jabbarpour, who along with her role with the Robert Graham Center, is a family physician and works clinically with MedStar Health, a large health system in Washington D.C.

The Robert Graham Center is a research center that aims to create and curate evidence to support primary care and policies that support primary care. The Center doesn’t do advocacy work. They are not policy makers, but researchers who study primary care issues, such as healthcare access, the demographics of the workforce, how much the country is spending on primary care, and the inner workings of the primary care system.

The Robert Graham Center is part of the research division of the American Academy of Family Physicians, but editorially independent. “We ask and answer questions related to primary care.  We may have set hypothesis when we enter the process, but we publish what our data shows us, whether that shows that primary care is excelling or that there is work to be done,” Dr. Jabbarpour said.

In an interview with the Journal of Healthcare Contracting, Dr. Jabbarpour discussed some of the Center’s recent findings, reasons behind the workforce shortages and physician burnout, as well as what can be done to better emphasize primary care in the United States.

Journal of Healthcare Contracting: Along with the research on vaccination history, what are some recent studies conducted by the Robert Graham Center to give us a better feel for the work you do?

Dr. Yalda Jabbarpour: We did a series on primary care’s historic role in terms of telehealth, looking at the capacity of primary care to take on telehealth visits during the COVID-19 pandemic. We used past data on what people basically go see the doctor for. We took those visits and asked ourselves which of these visits could reasonably be done via telehealth? Things like counseling about your weight, quitting smoking, depression or anxiety counseling, etc. And then which visits did you need to come into the office for, like a Pap smear.

So we divided it up and basically did a calculation that showed something like half of these visits could be done via telehealth and half had to be in person, which was important to know. So traditionally for what primary care does, half of our visits could be done via telehealth. But the important flip side to that was you can’t just have telehealth for primary care, right? You need to actually go into the office because half of the visits do require being in front of a doctor.

I also publish a lot myself with the Graham Center team. My work is around diversity, equity and inclusion of the workforce. I’ve published a series of briefs along with research collaborators at the American Board of Family Medicine. We have data on family physicians and their race, gender and salary, and who they treat. We have one study out that demonstrated that the gender wage gap exists for family physicians. We have another coming out that shows that Non-Hispanic Black and Hispanic family physicians take care of vulnerable patient populations at higher rates. Several more in this vein are coming out this year and next in the Journal of the American Board of Family Medicine.

Journal of Healthcare Contracting: What about workforce data and studies in general? We know staff shortages are a big issue. What are you seeing there?

Dr. Jabbarpour: We did a big study on this years ago, before COVID. At the time we estimated based on modeling about the age physicians retire and who was coming into the workforce that by 2035, we would have a shortage of around 40,000 primary care doctors.

It wasn’t just a shortage; there was also maldistribution. So just like any other physician group, doctors are in suburban areas or well-resourced urban areas and not necessarily urban, underserved areas, or rural areas. Although we did find overall family physicians do a better job in terms of being distributed in urban, underserved and rural areas than other physician groups.

In terms of burnout, studies are showing that young female family physicians are burning out at higher rates than any other demographic. We estimate that in 2026, the workforce of family physicians will be 50% female and growing. So if they’re also burning out at higher rates, that has huge workforce implications, which has huge implications for patient access.

We’ve investigated the reasons for the burnout. We’ve done a study with the American Board of Family Medicine that was happening prior to the COVID-19 pandemic. A lot of primary care physicians feel like they don’t have the support in their clinics to meet all their patients’ medical and social needs. Administrative tasks take time away that they are able to spend taking care of their patience and practicing medicine.

And I think the COVID-19 pandemic added concerns over safety for the doctors themselves and their family members, especially in the beginning when no one was sure how it was spreading. Do we need masks? Do we not need masks? How do we get PPE to outpatient physicians? Because PPE was available in the hospitals, but not necessarily for these outpatient physicians. So all of those things added to their burnout.

Journal of Healthcare Contracting: Are you seeing any solutions to the shortages and burnout?

Dr. Jabbarpour: So that’s been interesting. We’ve done focus groups and interviews asking physicians what solutions their employer has tried. And the answer has been, “My employer has tried nothing,” universally.

The problem of burnout is caused by the system and how the system is set up, all those things that I just went over with you are what’s leading to burnout. But the solutions are very individual. What we’ve heard, particularly from women, were that some physicians were deciding to go part-time. But when you go part-time, that’s hindering your access to patients. It’s also contributing to the gender wage gap. Other solutions were that these physicians were seeing a therapist or joining a support group. Those are all very individual-based things.

We did hear some employers tried mandated wellness retreats and mandated “let’s get together and talk about how we’re feeling” type initiatives, but the physicians felt those were just eating into the time that they could be getting some other work done.

Some physicians said hiring more staff was great. But it was a very minimal number who had actually experienced that. The ones who did have scribes or more robust teams seemed to be much happier.

People who didn’t have that wished for it. When we asked them, “OK, so your employer has done nothing. What could they do?” They said, “More support, more staff support like scribes to help write our notes, more social supports for the patients, and more time allowed during the office visit for patients.” It all came down to those kinds of things.

Journal of Healthcare Contracting: For a little perspective, how much does the United States spend on primary care? And how does that compare to other countries?

Dr. Jabbarpour: In terms of percent of total healthcare spend, between 5% to 7% of total healthcare spend is spent on primary care in the United States. It changes year to year, but 5% to 7% of the total spend is what the estimates are.

How that compares to other countries? Most other developed countries who are doing better in terms of outcomes are spending closer to 14%. So that’s double what we’re spending on primary care.

Journal of Healthcare Contracting: Why is there a disconnect between the underfunding of or emphasis on primary care and these outcomes?

Dr. Jabbarpour: That is a difficult question. I think it’s multifactorial. On the patient end, I think we live in a society where everyone expects a specialist, so it’s driven somewhat by that.

In primary care, what we do is prevention, and no one wants to pay for prevention. As a society, we don’t see the importance of prevention. We see, “When you get cancer, do we have the number one treatment in the world to treat that cancer?” And the answer is yes, we do.

But shouldn’t we be valuing conversations and counseling about smoking cessation and obesity, things we know contribute to cancer, as much as we value the newest cyber knife therapies? So I think part of it is that we as a society put more value on treatment than prevention.

The second thing is the way it rewards procedural services over prevention services. You do a procedure in the office, you’re going to be paid a lot more, and I think pay translates into value and how much a society values something.

Journal of Healthcare Contracting: In the past we’ve heard a lot about attempts made for value-based reimbursement, but is there anything out there that’s moving toward that?

Dr. Jabbarpour: Yes. The health systems that are following these value-based models tend to have better outcomes in terms of just getting preventive services done, patient satisfaction, and driving down costs. I think there are little pockets where health systems are really focusing on value-based care and moving away from fee-for-service care. But it has not spread as fast as we would like.

One of the reasons for that is, how do you define value? A lot of the metrics we currently have to define value aren’t really patient centered. The patient doesn’t care if their A1C for diabetes is below seven, and the doctor really doesn’t have much control over that because it’s not like we’re controlling what the patient eats, or if the patient takes his or her medication.

Patients care that they’re able to go to work, that they’re living a happy life, that they can walk, that they feel healthy. That kind of stuff is so hard to measure. I think that’s part of the reason why value-based care is not spreading.

The second part is, these value-based models require upfront investment, and you’re basically trusting that you’re giving this money and the clinic is going to use it in the best way that they feel to serve their population. There have been good outcomes, sure, but are payers willing to do that?

But yes, value-based care is the movement we want to see. That is what we believe, based on research, not just anecdotally, would lead to a healthier healthcare system.

Journal of Healthcare Contracting: What are your thoughts on how we prioritize the role that primary care physicians play in patient health and wellness?

Dr. Jabbarpour: That’s a great, great question. So number one, we need to spend more on primary care. When I say that, I don’t mean we need to pay doctors more. People may only hear, “Oh, the primary care doctors want more money.” But that’s not what this is about. When we increase the spend, we show the value of that service to society and we give primary care offices the resources they need to serve their patients. An increase in primary care spend will allow more resources to go towards primary care offices. Those offices know their patient populations well and can spend that money in the way they see most fit to meet the needs of their population.

Some clinics may choose to use that money to hire scribes and more staff to make things better for their physicians so that their physicians can focus on doing medicine. Some clinics might find that they need the money to invest in a robust EHR system so that they can do population health management and keep their patients out of the ER and out of the hospital. Some clinics may use that money to hire community health workers because their population has a mistrust in traditional medicine and rely on people who live in their neighborhoods for advice.

If we could increase the spend and funnel that money directly to the primary care clinics, and have them make a decision on how they spend that money to best serve their patients, I think that’s one way that we start to prioritize primary care and preventive health.

The second part is to change the fee schedule so that the primary care offices are getting paid more for preventive services. Preventive services are not sexy. It’s not sexy to tell someone to quit smoking or lose weight. It’s much more appealing to patients to be able to inject their knee with steroids and have them walk around immediately, or do minor procedures in the office that give them immediate satisfaction. That seems much more appealing, and while those procedures are needed, it’s prevention and control of chronic diseases that needs to be valued more. I think reimbursement needs to be adjusted to demonstrate that we do value prevention and chronic care management, and we are going to pay fairly for the time and effort it takes for physicians to offer these services.

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