As the U.S. healthcare system moves forward in its shift from a volume-based to a value-based payment system, where does primary care fit into the picture? In particular, how does primary care fit into the emerging financial ecosystem in healthcare? These questions were posited to two healthcare industry thought leaders at a recent panel discussion in New York City on primary care policy and health care reform, hosted by NYC-based Primary Care Development Corporation.
During the afternoon Primary Care Summit on Feb. 26, Mitchell Katz, M.D., the new president and CEO of NYC Health + Hospitals, New York's 11-hospital municipal health system, provided his perspectives on health care reform issues as both a seasoned primary care doctor and a public healthcare executive. Prior to his post as CEO of New York’s safety net health system, which he began in January, Katz led the Los Angeles County Health Agency, an agency that combines the Departments of Health Services, Public Health and Mental Health into a single entity with a $7 billion budget. Previous to that, Katz served as the director of the second-largest public safety net system in the nation, the Los Angeles County Department of Health Services (DHS), where he created the ambulatory care network. Katz also served as the director and health officer of the San Francisco Department of Health for 13 years.
Now leading the nation’s largest municipal health system, which is facing a $1.8 billion budget gap in 2020, Katz has said in previous media interviews that he is focused on continuing to push NYC Health + Hospitals’ focus from hospital care to primary care.
The panel discussion was moderated by Louise Cohen, CEO of Primary Care Development Corp., and joining Katz on the panel was Elisabeth Rosenthal, M.D., editor-in-chief of Kaiser Health News and a former emergency department physician. Rosenthal was also a reporter at The New York Times for 22 years, covering health and health policy issues, and recently authored a book, An American Sickness, about the U.S. healthcare system. Katz and Rosenthal shared their perspectives on the challenges facing primary care in the ongoing health care reform debate, and touched on the use of health IT as both a barrier and an opportunity to improve care.
Discussing the rising cost of healthcare for patients, Rosenthal noted that she was working in New York City ERs in the 1990s when Former U.S. President Bill Clinton’s proposed healthcare reform bills failed to pass. “Here we are, 25 years later, still talking about many of the same problems,” she said, adding, “Back then, healthcare wasn’t working for the poor and uninsured. Now, we’re in a different and more critical situation. We’re talking about the same issues, but on steroids. The crisis of healthcare affects all of us, and, politically, it’s an opportunity for change. My colleagues can’t afford healthcare, so not only is healthcare inaccessible, but with rising costs, it’s expensive.”
Sharing her thoughts on what could be done to improve primary care to the benefit of patients, Rosenthal said price transparency and patient education are both critical. “Part of it is getting patients to know what is value in care and what is necessary. Patients need to change too, we need to change to a culture of what it means to be a patient and what we expect to be the norm. The patient expectation now in our culture is that patients expect doctors to ‘do something.’ The key to primary care is talking, listening, watchful waiting, but there’s no money to be made in watchful waiting. The doctor training also is to ‘do something,’ order a test, do a procedure, we have to shift that,” she said.
Katz, who referred to himself as an “unapologetic primary care doctor,” agreed, saying that he views primary care as foundational to shifting the U.S. healthcare system to provide better outcomes at lower cost. “The special sauce is the longitudinal relationship with patients, and that can’t be replaced by technology or the smartest diagnostician. People want different things from their healthcare and only by knowing what they want, then you can steer them in ways that will not further inflame healthcare expenses.”
Katz also said that addressing social determinants of health was imperative to bending the healthcare cost curve, and an area that primary care physicians are well-suited to address. “Making sure that people have a place to live, food to eat, a safe environment to live. I’m hoping as primary care doctors are naturally focused on what patients need, that’s how we can address their housing, their food, whether they are living with a violent spouse, whether they are drug addicted, have serious mental health issues; primary care doctors are comfortable thinking about those issues, and I think that would make a huge difference in the cost curve.”
Rosenthal also said, “I tell doctors to get away from what I call the ‘why don’t we just…’ culture in medicine—why don’t we just get a CT scan or a MRI? Think about why you’re getting it. We have to reach medical students and move away from the ‘do something’ culture to think about chronic care and prevention and that’s hard right now given the current payment system.”
Rosenthal also noted that technology can be leveraged to enable more face-to-face time between physicians and patients. “There is tremendous potential in things like the digitization of records, online interactions, telemedicine. I think all of these technologies can be used to give physicians and patients more face time, which is what we want and need.”
She added, “When technology is applied well, and some health systems are doing a great job, then it’s a great adjunct to primary care, but it shouldn’t replace the doctor-patient relationship.”