Primary Care Delivery Is in Urgent Need of Innovation

The American Journal of Accountable Care. 2024;12(1):35-37. https://doi.org/10.37765/ajac.2024.89524

Although most clinicians understand the US health care system is a broken model, sometimes they might not realize just how broken it is, said Ken Cohen, MD, executive director of translational research at OptumCare, at an Institute for Value-Based Medicine (IVBM) event cohosted by The American Journal of Managed Care and Optum. During the evening event, speakers emphasized that innovation is urgently needed in primary care delivery.

For all that the US spends on health care, it doesn’t deliver a product of as high a quality as that of many other countries, Cohen said. During the IVBM event, he and other speakers discussed how to fix primary care in the US.

Optum Health is made up of more than 40 medical groups, all of which are heavily into financial risk. Over the years, data have shown that in order to move the needle on costs and quality, clinicians have to be practicing in a risk environment, otherwise it is very difficult to make a difference.

“If you take one point home, it’s that more care doesn’t equal better care,” Cohen said. “And that’s one of the reasons that our health care system is so dysfunctional; it’s because it’s estimated that about one-third of the health care provided in this country doesn’t improve health outcomes and doesn’t improve quality of life.”

To illustrate the issue, he showed a cost/quality scattergram of 1-year survival rates and total inpatient costs for Medicare beneficiaries with myocardial infarction, colon cancer, or hip fracture.¹ The chart clearly shows that there is no relationship between cost and quality, but a small number of providers practice at what is considered the optimal intersection of quality and efficiency, providing the highest-quality care at the lowest cost.

Cohen considers thyroid cancer screening in South Korea in 1999 to be a perfect example of harmful care. The government screened the entire population for thyroid cancer, even though the disease had very low mortality. Diagnoses of thyroid cancer increased 13-fold over a decade under the program, but many of the diagnosed cancers were indolent and some patients underwent harmful care such as a thyroidectomy or ablative radiation therapy.

“Mortality didn’t change at all,” Cohen noted.

Optum is addressing low-value and wasteful care through the Optimal Care model, which embraces the fact that the US has a dysfunctional health system and relies on physicians to be the solution.

“[The US health system is] not going to be fixed by governments, not going to be fixed by health plans, [and] not going to be fixed by hospitals,” he said. “If the solution is not physician-driven, it isn’t going to happen.”

The model also includes provider-focused, evidence-based education to drive decision-making by putting the evidence in front of the physician at the point of care.

The model also looks at referral and site-of-service optimization to understand the most efficient place for a procedure to be done. Cohen said the model is beginning to measure patient-reported outcomes as well, although it has just scratched the surface.

Primary care providers have had value-based care (VBC) models for years, but Optum is testing specialist VBC models. Across the country, 93% of payments to specialists are fee for service, and they receive the same pay for high-value care as they do for low-value care.

“So until we start spending money wisely, in terms of incenting our specialists around value-based care, the needle is not going to move very much,” Cohen said.

Morven Malay, DPT, OCS, PT, an orthopedic specialist with OptumCare, followed with a discussion of a new model for osteoarthritis (OA) care that follows the Optimal Care model with patient-reported outcomes measures, shared decision-making, and evidence-based care.

OA is a great candidate for VBC because of the patient and economic burden. It is the fourth leading cause of disability worldwide,² with $72 billion in direct costs and $12 billion in indirect costs.³ In addition, as the population ages and the obesity rate increases, so does the rate of OA.⁴ Yet less than 40% of patients receive evidence-based interventions.⁵ For 31% of patients, total knee replacements are inappropriate,⁶ and 25% of patients continued to have pain and disability after a total joint replacement.⁷

These data all point to improvements needed despite national and international guidelines for OA, Malay said. In the guidelines, the list of nonoperative care options is extensive, but many of them are behavior and lifestyle changes, such as exercise, weight loss, and smoking cessation.

“If any of you have ever tried any behavior change yourself, you might recognize that it’s hard. It takes a very personalized and complex process,” Malay said. In addition, the evidence-based guidelines and nonoperative care cross domains, requiring a comprehensive multidisciplinary approach that includes primary care, orthopedics, physical therapy, and more. However, many health care organizations continue to operate in silos, which creates a poor patient and provider experience.

Malay presented a common scenario in which patients with OA receive good evidence-based care but struggle to stay on the program that recommends weight loss and physical therapy. They often believe the myths that pain is an indication of damage from wear and tear that will get worse if they exercise and that the only way to fix it is with a joint replacement. As a result, the patient may stop attending physical therapy, become frustrated at the lack of improvement, and believe a joint replacement is inevitable. However, this patient might not need surgery yet.

“Osteoarthritis itself is a very complex experience impacted by what’s happening physiologically, biologically, [and] structurally, but also what’s happening psychologically and socially, as well as other comorbid conditions that might be going on,” Malay said.

Approximately 75% of patients with hip and knee OA have pain-associated psychological distress, such as anxiety, depression, fear avoidance, pain catastrophizing, and low self-efficacy and resilience,⁸ which all impact the outcomes of any prescribed intervention. Just focusing on the biological domain is not enough; treatment plans must also include psychological and social domains.

Optum’s OA care program addresses all the components of OA by coordinating care between the primary care physician (PCP), the physical therapist, and the orthopedist. The physical therapist is trained in cognitive behavioral–informed skills to help address sleep health in OA, nutrition, weight management, and other behavior strategies.

“This program is heavily focused on measurement and personalized approach, so [it’s] taking in patient-reported outcome measures to really be able to deliver a personalized experience,” Malay said.

Preliminary data from the early program have shown significant improvements in patients’ function, pain, and mental health outcomes across disease severities.⁹ The results were typically seen early in care (from 6 weeks to 3 months) and were maintained for a year, she said.

Ultimately, she said, OA care is about building a culture around treatment. “This is not just about helping patients through behavior change, but it’s also about…building a culture around the providers so that we’re all speaking the same language [and] the same message to really deliver this high-value care,” Malay concluded.

The next speaker was Mohammad Q. Khan, MD, president and CEO of Independent Physicians of Wisconsin, who highlighted how PCPs are uniquely positioned to help reduce the unsustainable rise in US health care costs.

Although health care costs are rising substantially year over year, very few actors in health care actually try to rein in the costs, Khan said. Compared with other countries with similar market-based economies, the US spends significantly more per capita on health care. In 2022 dollars, the US spent $12,555 per capita, which was almost twice as much as the average for comparable countries ($6651).¹⁰

Hospitals, pharmaceutical companies, equipment manufacturers, and laboratory and diagnostic centers have no interest in reducing health care spending, and insurers have too many hurdles to enact changes that would reduce spending, which means the responsibility falls to PCPs, Khan said.

“We have long-term relationships with patients. Patients trust us. And [PCPs] have a complete picture of patients’ physical, mental, and financial situations,” he said. However, many PCPs are employed by hospitals and health systems that profit from higher spending. “Somehow, we need to switch those PCPs from [the health system] side to [the independent] side of the scale,” he said.

There needs to be an incentive to switch sides, and Khan pointed to the performance of the Accountable Care Coalition of Southeast Wisconsin as proof that independent physician groups can save money while providing better-quality care than a large health system. Research into CMS’ accountable care organization (ACO) program has shown physician-led ACOs outperform those led by hospitals or health systems.¹¹

In the current health system, there is no reward, other than personal satisfaction, to educate the patient and focus on preventive care, Khan said.

“It’s [easier] to write a $1500-per-month prescription to the patient than to sit down with the patient for a half an hour and talk to them about the importance of losing weight and changing their habits,” Khan said. “But this is the way our health system is built. And unless we try to change it, I don’t think things are going to change.”

In the final presentation of the night, C. Todd Staub, MD, FACP, senior vice president, physician relations, for Optum, stated that innovation in primary care can help address physician shortages, inefficient workflows, and lack of access to care.

Although hospitals are not the enemy, and they are an important part of the health care system, they shouldn’t “rule the world” or “run everything in a market,” he said. The US needs a primary care–centric delivery system, because “primary care creates value,” he said.

As someone who practiced primary care for 30-plus years, Staub said that the state of primary care is the worst he has ever seen. The US population is aging rapidly and the Medicare population is doubling, but there’s a physician pipeline issue, he said. There aren’t enough PCPs today, and there won’t be enough in the future, because the physician workforce is aging along with the rest of the country, and when they retire, there won’t be enough PCPs to replace them, he said.

Any models of care being built need to consider the workforce shortages and the workforce that is there. He noted that there is a surplus of nurse practitioners and physician assistants, who must be included in the new models of care. “They’re part of the solution, and we have to really be mindful of that,” Staub said.

The patient, the end user, also has to be involved in the design of anything new.

“We’re famous in health care for building things in a back room, and we think, ‘Oh, we know the solution to your problem, we’re going to build this whole program.’ And then we roll it out and patients don’t like it—because we didn’t ask them,” Staub said.

With the shortages in primary care, it’s becoming important to make each person more efficient and productive.

Two of the pain points Optum is looking to find innovative solutions to for a better care experience are electronic health record note documentation and task bucket/inbox management. It is now using artificial intelligence (AI) to document conversations between patients and physicians, saving providers 90 minutes each day. Optum is also in the early stages of using AI to sort through tasks in the inbox, starting with prescription renewals in phase 1 and laboratory results and patient messaging in phase 2. Part of the goal is to automatically delegate some of the tasks to other team members.

Solutions to challenges in primary care have to hit all 4 quadrants of the Quadruple Aim: affordability, quality, patient experience, and workforce satisfaction.

“Shouldn’t we feel good every day seeing patients? And come away, at the end of the day, feeling like we had a really productive day [and] we made a difference in the lives of people?” Staub asked. “This is why we’re here. This is why we went into health care. So if we can come up with solutions that hit 2, 3, or all 4 of those quadrants, those are going to be the ones that we really need to focus on.”

Author Information: Ms Joszt is an employee of MJH Life Sciences^®, parent company of the publisher of The American Journal of Accountable Care^®.

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