November 16, 2023 was a glorious day for weather in our nation’s capital with a high of 66℉, endless rays of sunshine, hardly a cloud to decorate the bright blue sky — and for conversations about advancing high value primary care. I was thrilled to join other members of the Primary Care Collaborative for their annual summit to spend a day dedicated to reigniting our combined passion for our collective work, and to plot out how to advance primary care’s foundational role in shaping the future of U.S. healthcare.
The Primary Care Collaborative (PCC) is a not-for-profit multi-stakeholder membership organization that advances comprehensive primary care to improve health and healthcare for patients and their families by convening and uniting stakeholders around research, care delivery and payment models, and policies.
This year’s PCC summit started with a briefing on Capitol Hill, including a fireside chat with Senator (D) Sheldon Whitehouse, JD of RI, hosted by the PCC’s President and CEO, Ann Grenier. PCC members, Congressional staffers, and members of the press gathered in the Capitol Building to hear from several industry experts about the growing crisis in primary care, why stakeholders from across the industry are uniting behind the efforts to strengthen primary care, and what Congress can do to help.
Senator Whitehouse had some strong but insightful opinions about healthcare, and he didn’t sugar coat his words, sharing the following thoughts and comments:
He took a strong position on fee-for-service in primary care: get rid of it, and prior authorization along with it. (The rationale: Fee-for-service payment is toxic to the values of primary care, and prior authorization doesn’t make sense in the only discipline in healthcare designed to save money on total costs of care – not spend it.)
He acknowledged the mixed outcomes data on accountable care organizations (ACOs), but noted that one outcome is clear: primary care-led ACOs out-perform hospital-led ACOs, making a case that hospital-led ACOs should be eliminated. However, since not all primary care-led ACOs perform similarly, he asked that we help better inform the advocacy efforts of Congressional leaders by identifying which ACOs are performing best and mapping their locations to Congressional districts and their respective leaders to support their advocacy.
He took a moment to mention some flawed thinking in the Congressional Budget Office when calculating the return on investment of primary care. The financial impact of strong primary care, he said, takes many years to realize. In order to project appropriate upfront investments in primary care, out-year savings must be considered.
Finally, Senator Whitehouse captivated the audience by declaring, “We don't have a child mental health problem in this country, we have an adult irresponsibility problem.” He went on to describe that active shooter drills in schools and on university campuses, existential climate threat, social media toxicity and the like are undermining the mental health and safety of our children, and it is the responsibility of adults to intervene with the kinds of policies and actions that would reverse these trends and make our nation safer for children. Yet, to date, we’ve lacked the political will to do so. While this message does not directly tie to the primary care narrative, he also mentioned our strained mental health system, which is struggling to respond to crises on multiple fronts, and the crucial role of primary care as both a multiplier of and a gateway for mental healthcare access, citing behavioral health integration with multidisciplinary primary care teams as a partial solution.
As the day wound to a close and Ann Grenier tendered her wrap up remarks, she offered the stage and microphone to a particular PCC member for a couple of unplanned remarks. With a glint of mischief in his eye, Dr. Robert Berenson launched into a couple of hard-to-hear, “Did you know?” facts, including:
Medicare invests less than 4% of its total annual expenditures on comprehensive primary care, yet 6% on dermatology. This is some interesting food for thought when one considers that the specialty of dermatology is limited to the treatment of conditions related only to skin, hair, and nails, versus primary care which treats many of the same conditions (e.g. skin lesions, acne, nail fungus, eczema) but also every other organ system and body part in the entire human body – and only one of these specialties improves population life expectancy and decreases total cost of care.
The Medicare fee schedule pays $172 to freeze 15 or more skin lesions – actinic keratoses, for example – with liquid nitrogen — while also automatically assuming it takes 23 minutes to treat a single lesion. It takes the average clinician less than 5 minutes to accurately diagnose skin lesions in need of this particular therapy, 1-2 minutes to retrieve the liquid nitrogen canister, 15-30 seconds to treat each lesion (7.5 minutes total for 15 lesions, if you are slow), and a minute or two to give the patient some parting recommendations about aftercare of the treatment areas and follow up. All told, this adds up to about a 10-15 minute encounter – to treat 15 benign skin lesions.
Comparatively, a primary care physician who bills a 99215 E&M code gets just 8 additional dollars for spending 20 minutes managing a chronically ill patient with multiple medical conditions (e.g. diabetes, heart failure, chronic kidney disease, asthma) for a total of $180 by Medicare for this complex, cognitively dense work..
The amount of cognitive effort required to treat actinic keratoses with cryotherapy is completely obscured by the effort required to spend 20 minutes with a complex, multi-chronic disease patient. This stark contrast was a powerful talisman for the audience to take away from the summit as daily inspiration for the ongoing need to advocate for payment reform to better support primary care.
One standout experience of the entire event was a reminder of the risk primary care physicians face in our current environment: The audience watched a video testimonial of a woman who had the same primary care physician (PCP) for 30 years. She described the profound impact of this longitudinal relationship on her whole-person health and quality of life, while also watching her beloved PCP become increasingly stressed and burned out due to external forces that robbed this physician of her autonomy and demanded increasing and unreasonable daily workload from her, while simultaneously decreasing her operational support. This patient’s single story was an overwhelmingly compelling case for meaningfully supporting primary care, and certainly a piercing reminder of why we do the work we do.
The PCC demonstrates its value and relevance year after year, with this summit being no different. Conversation, exposure, and actionable steps driven through the summit and PCC’s stakeholders are essential to advance primary care. Only by making change to all levels of healthcare, from policy to patient, will we reinforce primary care’s essential role as the foundation of the U.S. healthcare system.
Sara J. Pastoor, MD, MHA is Elation's Senior Director of Primary Care Advancement and leader in primary care advocacy. Dr. Pastoor is a board certified and clinically active family medicine physician. Her experience as a primary care innovator spans a career in military medicine, academic medicine, private practice, and employer-sponsored delivery models. She received her MD from Rosalind Franklin University of Health Sciences and MHA from Trinity University.