COVID-19 is a catalyst for change. Even as each of our 7 organizations took immediate actions to support our 400,000+ members and diplomates, we knew the long term viability of the US health care system, and US primary care, required a unified long term vision.
During the summer of 2020, we developed a new paradigm for primary care financing, with convening and facilitation support from the Larry A Green Center and X4 Health.
In this vision, we are unified: By fundamentally changing the way primary care is financed, clinicians will be able to offer care that achieves better health, seamless integration of care, health equity, and lower costs.
We invite all those interested in the future of our health system to join us in collaborative work to strengthen primary care for the American people.
I
Our Open Letter for Change
Dear policy makers, payers, purchasers and the public:
Our health system is failing, and the pandemic is expediting its collapse. Life expectancy is in decline, the prevalence of chronic illness has risen, and disparities in health outcomes have deepened. Our health system isn’t just broken – it is bankrupting many in our country.
The current financing of U.S. health care was designed almost 60 years ago to shield against financial loss from serious illness, rather than to meet modern society’s desire to invest in health and our future. This is a pivotal moment for our nation’s health, requiring a new paradigm for financing primary care and health promotion.
As physician societies and boards, our greater than 400,000 members are the source of trusted, healing relationships for 8 in 10 Americans, serving the health needs of the U.S. population through over half a billion annual patient visits.1 This essential role in the health system is currently supported by only 6% of all resources spent on health care,2 which is inadequate. The views of our seven organizations are not always the same, but in this we are united: in order to help the people of our nation achieve better health outcomes, reduce unnecessary health care costs and rectify social inequities, the U.S. must recognize and invest in primary care as a public good. To bring U.S. primary care on par with high performing countries would mean a relatively small shift in resources that stands to create tremendous improvement in health outcomes.
As leaders in the provision of primary and comprehensive care, we regard the responsible stewardship of the health of our nation as a sacred trust. There is a direct relationship between the kind of primary care we deliver and the way in which it is financed and paid. Advancing primary care as a public good will require shifting the paradigm of primary care financing, creating a unified approach among all payers, and dismantling the regulatory and financing structures that institutionalize the status quo.
We understand that what we are calling for is significant and will take substantial time and effort. We are committed to doing this hard work together. We invite other clinician groups and professional societies to join us in this journey toward better health for all of our patients. We will work in partnership with payers, purchasers, policymakers, and patients to bring a modern system into being. The health of the public cannot wait. The time for partnership and action is now.
Sincerely (Elected leaders and CEOs),
1National Ambulatory Medical Care Survey: 2016 Summary Tables. Accessed November 25, 2020.
2Martin S, Phillips RL, Petterson S, Levin Z, Bazemore AW. Primary Care Spending in the United States, 2002-2016. JAMA Intern Med. 2020;180(7):1019–1020. doi:10.1001/jamainternmed.2020.1360
American Academy of Family Physicians
Ada D. Stewart, MD, FAAFP, President
Shawn Martin, Executive Vice President and CEO Designee
American Academy of Pediatrics
Sara H. Goza, MD, FAAP, President
Mark Del Monte, JD, CEO and Executive Vice President
American Board of Family Medicine
John Brady, MD, Chair
Warren Newton, MD, MPH, President and CEO
American Board of Internal Medicine
Marianne M. Green, MD, Chair
Richard J. Baron, MD, MACP, President and CEO
American Board of Pediatrics
Victoria F. Norwood, MD, Chair
David G. Nichols, MD, MBA, President and CEO
American College of Physicians
Jacqueline W. Fincher, MD, MACP, President
Darilyn V. Moyer, MD, FACP, FRCP, FIDSA, Executive Vice President and CEO
Society of General Internal Medicine
Jean S. Kutner, MD, MSPH, President
Eric B. Bass, MD, MPH, CEO
II
Our Continued Support of the Shared Principles
Our Professional Commitment to the American Public and the Shared Principles of Primary Care
The Shared Principles of Primary Care were developed in 2017 through an effort led by the Primary Care Collaborative that involved more than 350 stakeholders representing all aspects of health care. We stand firm in our commitment to these principles. While the social and political environment continues to change, the foundational importance of these principles has not changed. Motivated by the extent to which the social drivers of health are deeply influenced by structural racism, we support elevating health equity to stand as its own principle, with renewed professional attention. We understand that a multi-stakeholder process to effect this change is underway.
We also affirm that it is critically important for all patients to have personal clinicians committed to delivering longitudinal, person-centered care as part of a healing relationship that embodies these principles, and to have a system designed to deliver proactive care to a defined population of patients.
III
A New Paradigm for Primary Care Financing
Investment In Health as the New Paradigm for Financing Primary Care as a Public Good
Securing the health of our nation requires fundamental change to the financing of primary care. Changing what is financially supported changes the ways clinicians will function and the care they are able to deliver. Investing in primary care will have positive ripple effects on the rest of the system in achieving better health, seamless integration of care, health equity, and lower costs.
The U.S. can no longer survive the current financing paradigm, which we call “Cost-Based.” The Cost-Based paradigm constrains payment to the cost of care delivery by clinicians, teams and systems rather than payment that encompasses the value of care received by patients. The Cost-Based paradigm is mismatched with the systemic need for integrated, person-based care delivery and the development of an appropriately skilled, internally motivated workforce. The financing of primary care should be based on the long-term health and value created for patients and populations, rather than on the historical costs to clinicians and systems as assessed through an antiquated model.
To deliver on our promise to the American public as stated in the Shared Principles, a new paradigm is required at every level – in U.S. public policy, among private sector payment and financing strategies, in health system organizations and more. That new paradigm would invest in primary care functions that promote optimal health for all members of society. With that investment, primary care physicians and their teams would be enabled to coordinate care locally, collaborate with community organizations and public health departments, and address known social drivers of health.Enabling primary care teams to support this paradigm requires specific investment. The Table below identifies dominant attributes of the current Cost-Based paradigm and presents a new Invest in Health paradigm for primary care financing.
The COVID-19 pandemic has exposed and amplified the many tragic and unnecessary vulnerabilities created by a financing paradigm ill-matched with the health needs of our population. The American people deserve better.
IV
Our Calls to Action
As a paradigm shift in regulatory structures and financing takes place, and we continue to honor the societal contract between primary care and the American public, we issue the following calls to action:
WE CALL ON:
Private and public sector payers to publicly commit to shifting the paradigm of primary care financing as soon as possible, and no later than the next 2 years.
WE CALL ON:
The federal government to work collaboratively with us to:
Apply a streamlined, real-time learning process for implementing new models of primary care financing that reflect the new Invest in Health paradigm -- both health promotion and financing goals.
Eliminate each regulatory structure and public policy that binds us to the current paradigm and identify ways to begin shifting toward the new paradigm.
Operationalize the new paradigm and its attributes in all primary care payment programs based on the real-time learning process and evidence of what works in the testing of new models.
WE CALL ON:
The federal government to increase investment in safety net programs, public health agencies, and community-based services and support so that they may partner with the medical care sector in addressing structural racism and social drivers of health.
WE CALL ON:
Our members and diplomates to advocate with both federal and state policy makers as well as payers to develop and test new models of primary care financing that facilitate rapid cycle learning and build support for national-level changes.
WE CALL ON:
Health care organizations to invest in existing community-based social services and ensure that the flow of dollars supports services such as food banks and other safety net programs that address social drivers of health.
WE CALL ON:
Fellow physician and clinician societies to:
Create a roadmap for dismantling the policies and regulatory structures that enshrine the current paradigm, and to build multi-stakeholder support for the roadmap; and
Report on progress toward the new paradigm shift each year.
WE CALL ON:
Other health care stakeholders to join us in the call for change by signing on to this statement.