How long has there been talk of “fixing” US healthcare?

How many times has your employer changed its health plan hoping to find a magic cure for ever-rising costs?

Despite the talk and changes so far, our government, employers and healthcare “experts” have focused on the wrong things all along!

We have had 40 years of alphabet soup healthcare “fixes” to prove it: HMOs, PPOs, ACA, ACO, PCMH, and let’s not forget wellness programs, high deductibles, HSAs and telemedicine as well.  Has healthcare become less expensive?  Has anything really changed?

The lack of measurable positive change has led some to believe that if we only had a government-run, single-payer, or one-model-for-everyone healthcare system like most other developed countries, all our healthcare problems would go away.

That belief is wrong, too.

Focusing On the Wrong Things All Along

What if I told you that rock-solid, undisputed research has existed for over 20 years on the most crucial factor that actually reduces healthcare costs and improves health outcomes?  Furthermore, strangely, this key factor never seems to be brought up in our hyperbolic healthcare debates.

Have you ever heard of the name Dr. Barbara Starfield?  I would be shocked if you have.  But, everyone should know about the results of her work.  It holds the keys to true healthcare transformation: lower cost AND better health outcomes.

What did this researcher and Head of Johns Hopkins’ Department of Health Policy and Management find over the course her highly-regarded 50 year career?:

A country’s per-capita healthcare cost and overall health outcomes are not driven by whether a country has a government-run system or is completely “free market”; instead, what truly matters is how well primary care is delivered.

Universal health insurance alone is not sufficient to raise a country’s health levels to match those of countries with the best levels.  Within the United States, there is a greater relationship between the presence of a good supply of primary care physicians and life expectancy than there is between either broad insurance coverage or affordability of coverage and life expectancy.  Universal coverage alone, particularly if not organized through a single payer with uniformity of benefits, could expand access to inappropriate services. SOURCE

That’s right: the reason other developed countries spend less on healthcare compared to the US is NOT because they have some form of government-run system.  Rather, how a country’s primary care is structured and delivered is what is paramount; how one interacts with one’s internist, family physician or pediatrician is the most important determinant of cost and outcomes.  Said differently, what matters is the strength of the relationship between you and your personal, primary care doctor.

All the talk about payment, insurance coverage, deductibles or network size is wasted oxygen until the primary care piece is set up correctly.

You might be thinking: “Come-on, how I interact with Dr. Smith, my primary care doc, the guy I see for 10 minutes if I have a sinus infection, impacts my life expectancy and is the reason why the US spends 20% of GDP on healthcare versus 10-12% like other developed countries?

Yes, that is absolutely right!

How So?  Let’s Walk Through It

What is the part of our healthcare system that we interact with the most?  Answer: Primary care.

Now, think about the prescriptions you or a family member take, or the specialists that you or a family member see, or the times that you or a family member had to be admitted to a hospital.  Now, where did those prescriptions, referrals and admissions originate?

That’s right: a primary care physician, “Dr. Smith”!

When we boil it all down, the relationship between you and your primary care doctor is central – it is the relationship that triggers all other, much more costly, downstream healthcare utilization.

Primary care is not only central, but also the “front door” or “intake” of the US healthcare system.  In other industries, there is a saying “garbage in, garbage out,” – meaning: if the intake is not set up correctly, the entire system will produce failure.  One could apply that same saying to the US healthcare system.

The US Healthcare System Does Not Value Primary Care

One might think that with their enormous impact on health and cost, primary care physicians would be highly valued.  Unfortunately, we pay primary care physicians the least of any type of doctor.  Furthermore, insurance companies, Medicare and Medicaid tell primary care physicians what to do, how to do it, and how they will specifically be paid.

Ever wonder why your primary care doctor will not simply treat you using the phone, email or text message?  That is because insurance companies, Medicare and Medicaid base payment to primary care physicians almost entirely on the number of patients a physician sees face-to-face in his office.  Primary care physician income is determined by how many patients he can see every day and, thus, is impacted by how quickly he can see each one.  The quality of each patient-physician interaction is largely irrelevant.  Plus, primary care physicians receive very little to no payment for phone calls, emails, texts, video chats, counseling a patient’s family regarding a treatment plan, consulting community social services, or anything else that could benefit a patient outside of the face-to-face in-office visit.

Furthermore, in order for a physician to receive payment, the required documentation or paperwork can take as long to complete as the visit itself.  On average, primary care doctors cover the salaries of 5 support staff per doctor in order to handle all of the paperwork.  Therefore, the payment rules I just explained provide primary care physicians no choice but to jam in 25-40 patients per day in order to achieve the “honor” of being the lowest paid type of physicians in the US.

Now, in light of these constraints, is there any confusion as to why we have terrible relationships with our primary care doctors in the US?  How are we supposed to achieve Dr. Starfield’s 4 Cs of great primary care and have a continual, comprehensive and coordinated relationship with someone whose only option to talk to us is in his office, as quickly as possible, and as he cycles through patient after patient?  Oh, and only if there is an appointment available – which, on average, must be made 2 weeks in advance!

Imagine being a primary care physician who endured 10+ years of training and now has to deal with this system.  Would you be happy providing less than your best to 25+ patients day after day?  Sadly, our overworked doctors have one of the highest suicide rates of any profession in the US.

Solution: We Need to Get to the 4 Cs of Great Primary Care, but How?

Physicians need freedom!

Our doctors need the freedom to decide how best to care for us, and, we need the ability to interact with them in a way that fits into our busy lives.  Insurance companies, Medicare and Medicaid shouldn’t be telling highly-intelligent physicians how to do their jobs and mandating exactly how physicians will be paid.

If our primary care physicians were free of paperwork, coding, documentation and top-down mandates, then, they could use all of their training, intellect, resources and available technology to care for us.  Physicians and entrepreneurs could innovate and figure out new ways to make access to primary care physicians easier, and new ways to provide care in a continual, coordinated and comprehensive manner.

How nice would it be if we could hop on a secure FaceTime with our very own local doctor instead of calling some random doctor through a telemedicine service?

Conclusion

How primary care is delivered is the most important factor in reducing healthcare cost and improving health outcomes.

So the next time you hear someone talk about how to fix the US healthcare system, whether coming from a politician, expert, your employer, benefit consultant or your uncle at Thanksgiving, ask him if he is aware of Dr. Starfield’s research.  Ask him how his great healthcare idea frees our primary care physicians from the constraints I mentioned so that they can achieve the promise of the 4 Cs.  Ask him what he thinks of the outstanding results achieved by certain primary care-focused providers like Iora Health, Qliance and ChenMed, whose physicians are free to provide care to patients in whatever way they deem best in order to achieve positive outcomes: whether that is giving a patient an iPod to quell her anxiety or showing a patient how much they care by calling her on the phone just to say “Hi.”  Ask him what he is doing to encourage the growth of the very promising Direct Primary Care movement?

As Dr. Starfield’s research proved, our ability to form strong relationships with our primary care doctors is crucial.  Only when we free primary care physicians from the existing insurance-based constraints and allow them and other entrepreneurs to innovate with new delivery models and technology, will we finally make US healthcare less expensive and produce better health outcomes for us all.

Tom Valenti is Founding Partner of Forthright Health (ForthrightHealth.com)  You can follow him here: @tjvalenti