‘Think big or go home’: Harvard wants to reshape primary care
This article is part of a series spotlighting people and institutions who are innovating in primary care. If you or your institution is taking important steps to improve the quality and cost of care in the primary care setting, email the editors at email@example.com. We want to hear from you.
Researchers at Harvard Medical School’s Center for Primary Care are tackling some of the biggest issues in the field — limited resources, reimbursement and burnout — both in the United States and abroad.
Their work so far has shown that investing in primary care resources and team building reduces overall health care costs while improving the quality of care, which in turn makes the field “more attractive as a specialty” to medical students, according to Russ Phillips, MD, director of the Center for Primary Care.
“Those who are thinking about going into primary care want to have resources available in order to take care of patients,” Phillips, who is also the William Applebaum Professor of Medicine and professor of global health and social medicine at Harvard Medical School (HMS), told Healio Primary Care. “We can demonstrate that there is sufficient revenue to cover some of the costs of these resources within primary care practices, while, for others, primary care spending needs to increase to meet important needs.”
Creating the Center for Primary Care
After funding for primary care was suspended at Harvard in July 2009, students and faculty started a petition to support primary care education at the university. The petition accrued nearly 1,200 signatures in 3 months, according to HMS.
The idea of creating a primary care center emerged from a series of Town Hall meetings hosted by faculty and students. Their mentality was “think big or go home,” Phillips said.
“It seemed smart, thinking about the social responsibility of Harvard, to create a center that would make primary care more visible,” he added.
Phillips and David W. Bates, MD, professor of medicine at HMS and professor of health policy and management at Harvard T.H. Chan School of Public Health, proposed a budget of $30 million for the creation of the center, which was later provided by an anonymous donor.
“Without that, we would not have had the impact locally or nationally that I believe we’ve had, as that has funded much of the activities at the center,” Phillips said.
Since the center opened in 2011, Phillips and his colleagues have explored the potential benefits of different health care models that address universal issues in primary care. One of these issues is the shortage of PCPs.
‘We can make primary care practice more attractive’
A report from the Association of American Medical Colleges suggests there will be a shortfall of up to 43,100 PCPs in the United States by 2030. The findings are potentially significant because a study by Harvard researchers published in JAMA Internal Medicine found that the availability of PCPs has an impact on mortality rates in the general population. Moreover, evidence suggests fewer Americans are receiving primary care. Between 2008 and 2016, visits to PCPs declined 24.2% among U.S. adults with commercial insurance, according to findings recently published in Annals of Internal Medicine.
“If you’re going to have a system of high quality at low cost, it needs to be based on a strong foundation of primary care. That’s one of the things that Harvard has been focused on,” Phillips said.
PCPs face numerous obstacles in daily practice, all of which can make the calling less appealing to medical students. Among them: excessive documentation using electronic health records and the uphill battle of prior authorization, according to Phillips. Other challenges include reimbursement and having enough resources to do the job. To that end, much of Harvard Primary Care Center’s work is spent researching ways to drive revenue into primary care practices.
“We have an initiative that I’m actually very involved in that’s looking at payment for primary care and how we can be paying differently for it,” Phillips said. “We have looked at global payment and showed that more than half the patients in the practice would need to be paid through global payment to afford needed changes in the practice. The fee-for-service system does not pay enough.”
Phillips and colleagues conducted a cost-benefit analysis of employing community health workers in primary care to manage patients with chronic health conditions. Using a microsimulation model, the Harvard research team found that a community health worker assigned a panel of 70 patients with uncontrolled hypertension would need to avert four to five visits to the ED each year to achieve cost-neutrality. Most other chronic conditions would require the community health worker to avert between 7% and 12% of ED visits to make it cost-saving — “theoretically feasible,” according to the researchers.
Engaging community health workers to improve patient outcomes is a big focus in primary care, according to Lindsay Hunt, director of systems transformation at Harvard’s Center for Primary Care.
“Already there’s a huge need that we’re having a hard time of meeting, much less of when we increase access to things like behavioral health,” she told Healio Primary Care.
Yet another microsimulation study from Harvard found that practices that rely on nonphysician team members to deliver chronic care management services can “experience substantial net revenue gains” if they enroll enough Medicare beneficiaries to offset the overhead costs of hiring additional staff. For example, a typical practice could get $75,000 of net annual revenue per full-time equivalent (FTE) physician and 12 hours of nursing service time per week if half of eligible patients enroll. At a minimum, that means at least 131 Medicare patients (95% CI, 115-140), researchers said.
The provision of the additional services that Hunt mentioned — namely, mental health care — is yet another research target of Harvard’s, particularly given that CMS in recent years has extended behavioral health coverage benefits to Medicare recipients.
Using the same microsimulation model as before, Phillips and colleagues evaluated the financial impact of plugging behavioral health services into the primary care clinic. They found that a collaborative care model — one that offers a follow-up telephone call from a behaviorist — was financially viable. Specifically, when behavioral health integration services were offered to Medicare patients, net revenue under the collaborative care model averaged $25,026 per FTE physician in year 1 and $28,548 per year in subsequent years. When commercially insured patients were added to the equation, the model still consistently gained net revenues.
Hunt said that integrating behavioral health services into primary care — such as screening and connecting patients to treatment — represents a “huge step forward for practices, especially given the stigma of behavioral health.”
“For people to be able to receive behavioral health services within primary care, or at the very least be referred to a specialist by someone in the primary care setting, significantly increases the chances that patient will pursue and connect to behavioral health care,” Hunt said.
The Harvard Primary Care Center is currently evaluating models for treating opioid dependence in the primary care setting as well, although their findings have not yet been published.
“These are all parts of efforts to model resources that could be available to primary care practices and determine whether there will be net resources that will flow into primary care practices to support physicians, teams and their work,” Phillips said. “If we can help relieve the burden through strengthening teams, we can make primary care practice more attractive.”
Increasing investment in primary care
Findings recently published in JAMA showed that, broadly speaking, the share of total spending on primary care decreased among those insured through their employers between 2013 and 2017. The percentage of spending on primary care, hovering around 8%, is much smaller compared with that of other countries, which can range between 20% to 30%, Phillips noted. Results are similar among Medicare beneficiaries — Rand Corp. researchers found that only about 2% to 5% of total Medicare spending was dedicated to primary care.
Phillips pointed to a study that he and his colleagues published in Health Affairs last year that showed Rhode Island — a state that doubled its spending on primary care over 5 years — reduced overall commercial health care spending. He said it serves as an important example of how states can slow health care spending growth through price controls while still investing heavily in primary care.
“In Massachusetts, the governor is actually calling to increase the amount spent on primary care and behavioral health by 30% based on the expectation that if we can invest more in primary care, we can reduce overall health care costs and provide higher quality care,” Phillips added.
Ann Greiner, president and CEO of the nonprofit Primary Care Collaborative (PCC), explained that the Harvard Primary Care Center’s research helps define the contours of cost-effective, high-quality care, and it also supports effective policymaking.
“I think of them as a critical resource to helping us understand what's working in the delivery payment reform space, and what's working in terms of policies. They inform our work in that way,” she said.
Advancing the medical home model
The Primary Care Center’s work extends beyond scholarship. It also works directly with practices in its region on systems transformation. For example, Harvard heads a program called Advancing Teams in Community Health — a 5-year initiative funded by the Health Resources and Services Administration that helps community health care centers across Massachusetts adjust to the patient-centered medical home (PCMH) delivery model.
“The work focuses on behavioral health integration, the use of community health workers and oral health integration into primary care,” Phillips explained.
The medical home model is a driving force behind the Primary Care Collaborative, of which Harvard is a member. Founded in 2006, the collaborative has been advocating for the PCMH approach to primary care, and since then, the model has been adopted by commercial health plans, state Medicaid programs and by the federal government, according to Greiner.
“And now, 42% of primary care physicians practice in a patient-centered medical home,” she said.
In addition to the Advancing Teams project, Harvard also runs the Primary Care Improvement Network, which helps practices in the Boston area work on team building in the PCMH model. Strong primary care teams — which can include physicians, nurses, physician assistants, nurse practitioners, social workers, behavioralists and community health workers — help practices deliver more comprehensive care such as safe opioid prescribing and referral of services for social determinants of health, Hunt said.
“If you’re treating somebody for depression who is living in a home where there is domestic violence, it is not a surprise that their medication is not working, so changing the medication isn’t necessarily going to have an impact if the underlying problem is still in existence,” she said. “Until patients are getting the support they need, no amount of primary care is really going to make a dent in the problem.”
The work appears to be paying off. Researchers found that 18 academically affiliated primary care practices in the Boston area that employed team-based care saw an 18% reduction in hospitalizations, a 25% reduction in ED visits and a 36% reduction in ambulatory care-sensitive ED visits among patients with chronic illnesses, compared with 76 comparator practices.
“What are we doing to address the personpower shortage in primary care?” Phillips asked. “We think a big part of the solution is to strengthen primary care teams. So, we’re strengthening primary care teams across the Harvard though to medical home transformation.”
New health care ventures
Another area the Harvard Primary Care Center is focused on is entrepreneurship.
“We think that a lot of innovation is going to come not so much from quality improvement efforts from within practices, but through the creation of entirely new approaches to care,” Phillips said.
For example, Harvard works with MIT to run a “health care bootcamp” — as Phillips put it — an accelerated learning program for students who want to develop entrepreneurial skills and start companies focused on health care.
Paola Abello, MBA, director of innovation at the Center for Primary Care, said the center offers courses, workshops, mentorships and a 10-month fellowship — all of which teach students “how to harness technology, medical know-how, business and design thinking to transform problems into viable business opportunities.”
“Of all the resources we offer, the connection to mentors is often the most valuable for aspiring entrepreneurs,” Abello told Healio Primary Care. “We do this because we know that transforming health care has to happen not only inside of our current health care systems but also on the edges, where the innovators and entrepreneurs often start.”
Improving primary care on a global scale
The goals of Harvard’s Center for Primary Care align with the global agenda of breaking down siloed care to achieve universal health coverage, according to David Duong, MD, MPH, director of the Program in Global Primary Care and Social Change and Healio Primary Care Peer Perspective Board member. This global agenda was initially established with the Declaration of Alma-Ata in 1978, when world leaders came to an agreement that “building a strong foundation of primary health care for all health systems was a way to achieve health for all by 2000,” he said.
“Obviously, that didn’t happen,” Duong added.
Implementing a comprehensive primary health care strategy was considered by many critics of the Declaration of Alma-Ata to be “too expensive and not feasible,” so countries began adopting “selective primary health care” in which specific diseases or conditions, such child and maternal health, immunizations, HIV and malaria, were targeted through individual health programs, according to Duong.
“Children were dying from diarrheal diseases and mothers were dying from childbirth, so people focused on these diseases and conditions one by one,” he said. “We’ve had amazing population health outcomes because of that, but we’ve also been left with a very fragmented health care system around the world. A clinic could have a remarkable HIV program, but it doesn’t have any offerings for diabetes, hypertension or just general well-being care.”
After recognizing the limitations of their health systems, ministers of health signed a second agreement — the Declaration of Astana — in 2018 to rededicate efforts for comprehensive primary health care. This new agreement along with the High Level Meeting on Universal Health Coverage at the United Nations General Assembly on Sept. 23, 2019, in New York, recommitted the world to achieve universal health coverage through a strong foundation of primary health care, Duong said. Harvard’s global primary care program is helping governments, private sectors, foundations and other nongovernment organizations deliver on this promise by providing knowledge and technical assistance, including training for health care workers and students, financing strategies, models of comprehensive primary health care delivery and initiating and scaling innovations in primary health care, all of which can vary depending on the country’s resources.
Most of the center’s international work has been conducted in Vietnam. Duong and colleagues have partnered with the Vietnamese Ministry of Health, the World Economic Forum and private sector stakeholders such as Novartis to implement a national team-based primary care strategy in the country with the support of investors and donors.
Harvard is also working with the Korean Primary Health Care Association in the Republic of Korea to strategize and promote a stronger community-based care system model, as well as the National University of Singapore to create executive education courses for PCPs and health systems leaders in the Asia Pacific Region.
The global work at Harvard is “bidirectional,” according to Phillips. While reforming health care systems in other countries, Harvard researchers are also learning more about the value of community health workers and, in Singapore, data sharing and artificial intelligence. Singapore uses an integrated EHR system in which each citizen has a national health account and identification number, according to Duong.
“No matter what hospital you go to in Singapore, no matter what clinic, providers are always able to access patient information,” he said.
Because everything is on one network, health care officials can target interventions based on AI, Duong explained.
“Maybe one neighborhood has a higher rate of diabetes or hypertension,” he said. “Data sharing can reveal what’s going on in that neighborhood so we can make a targeted intervention.”
Harvard researchers are also learning from the flaws of other health care systems. China’s response to the ongoing COVID-19 epidemic underscores the importance of having a strong primary health care foundation, according to Duong.
“During the onset of the outbreak, the Chinese health care system inundated with people going to hospitals. We saw from news reports that people were lining up at hospitals, waiting 7 to 9 hours in the cold to see a physician or health care provider,” he said. “Likely, many of them could have gone to a primary health care provider.”
Duong added that not all patients with the virus require hospitalization or need to seek treatment in the hospital setting.
“We could image a scenario in which there was a strong and robust primary health care system that could have taken a significant workload from the hospitals, preventing them from being inundated and depleting resources,” he said. “Hospitals are not meant to screen hundreds of thousands of people per day while providing high-tech and high-acute care. This is a great point to tie into why we need to invest in primary health care systems, especially in low- and middle-income countries — but really for any country.”
Association of American Medical Colleges. Physician supply and demand through 2030: Key findings. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/73/32/7332e443-2302-4daa-a56e-6937a43646ea/2017_workforce_projections_key_findings.pdf. Accessed Jan. 21, 2020.
Harvard Medical School. Primary Care Evolution. https://hms.harvard.edu/news/primary-care-evolution. Accessed Feb. 17, 2020.