Primary care must evolve to survive

Despite the growing market interest and investment in primary care, the profession and practice of primary care is in crisis. As it stands now, the very structure of primary care harms physicians and threatens its own future. In research we recently published in The Journal of General Internal Medicine -- done in collaboration with our colleague Dr. Russell S. Phillips of Harvard Medical School -- we identified a growing crisis in our field that is not sustainable for the future. The structural realities of practicing as a primary care provider (PCP) in our current health system are disheartening. We worry deeply for our current colleagues in addition to the next generation of physicians considering primary care.

Andy Ellner, MD: ©Firefly Health

Primary care is inefficient, inconvenient, and often inaccessible, optimized neither for patient experience nor positive outcomes. Consider the impact on health professionals and the situation looks even more dire.

Outdated approaches to care, administration, payment, and technology are not merely burdensome. They actively contribute to physician burnout and dissuade students from entering the field. COVID exacerbated these issues with added financial pressure and nearly unimaginable stress. It’s no wonder physicians currently seek care for anxiety and depression in record numbers. They also have higher rates of suicide than the general population.

Nisha Basu, MD: ©Firefly Health

PCPs are expected to meet the demands of both synchronous and asynchronous care along with mountains of administrative work. They’re trapped in a fee-for-service (FFS) system driven by payment, scheduling, and workflow software designed for revenue management. Let that sink in. The daily routines of the physicians at the foundation of our health care system are driven not by outcomes or value, but by revenue management.

That means a PCP’s days are packed with visits from patients who often require neither a physician nor an in-person visit. Despite receiving unique training to handle complex conditions, PCPs have less time than ever to see patients who need them most. This frustrates physicians and patients alike and leads to patients seeking care in expensive and inconvenient settings like emergency rooms.

A proper fix for primary care requires more than tinkering. It calls for a clear, evidence-based restructuring centered on value, outcomes, and engagement. What would that look like? Consider a primary care team where:

• Nurses triage patients via email, chat, and phone and intelligently route them to optimal care options
• Nurse practitioners (NPs) and physician assistants (PAs) provide most care for common conditions and serve as continuous contacts for patients
• Physicians guide NPs and PAs, manage patients with complex conditions, and focus on building trust and rapport
• Behavioral health specialists work in concert with the team, delivering short-term therapy and guidance to long-term solutions as needed
• Health coaches provide ongoing lifestyle support
• Pharmacists assist with medications and safety reviews
• Care guides coordinate care and navigate to specialists

Perhaps the biggest change in this restructuring is that the “doctor visit” is no longer the focal point for all care. Instead, care teams have clearly defined roles and supporting technology, like patient relationship management software, that allows them to efficiently provide care for how people actually live and work. They have, for instance, dedicated time for asynchronous care like creating care plans, consulting with remote specialists, and responding to patient chat messages, emails, and phone calls.

With planned asynchronous care and proper staffing, teams are empowered to respond quickly and frequently, establishing more opportunity for patient engagement and trust building. This has a secondary effect of reinforcing a simple and powerful idea: patients should reach out for care whenever, wherever they need it. The convenience of it all (a chat message returned within minutes versus a visit three weeks out) means fewer patients ignoring their needs or self-triaging only to end up in the ER.

Dedicated time for synchronous and asynchronous care, well-coordinated teams, and supportive technology enable clinicians to finish tasks and documentation during work hours. Plus, giving physicians agency, collaborative support, and clear avenues to quality improvement has been shown to reduce burnout and keep them working in fulfilling primary care positions for longer.

Outcomes-based care also holds tremendous potential for reducing health disparities. By tracking clinical outcomes, teams can respond to gaps in care both within populations and between populations. And care that takes advantage of expanding broadband availability removes access issues for people who live in rural areas, struggle to leave their homes, or have challenging work schedules.

The traditional in-person visit has built-in pressures on both physicians and patients. Shifting toward a more flexible, empowering care model grants clinicians the time to consult the literature and colleagues on complex cases. Likewise, patients can process difficult decisions in their homes and communities, reaching out to care teams over chat for continuous support.

This new model — a partnership across time, space, and clinical disciplines — allows physicians and patients to celebrate the challenges and wins together. In the process, it offers more human moments that spark joy in the practice of primary care.

Andy Ellner, MD, MSc, is a primary care provider and Firefly Health’s co-founder and chief clinical advisor. Nisha Basu, MD, MPH, is a primary care provider and vice president of clinical at Firefly Health.