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Reimagining Primary Care for New York's Patients

As more people gain health insurance coverage, and as the health care system looks to save money and emphasize keeping people healthy (not just treating them once they're sick), primary care is becoming more important than ever.
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Robert Derzon Chair in Health and Public Service at NYU

Robert Derzon Chair in Health and Public Service at NYU
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I was fortunate to be among a group of 40 to 50 people who recently spent a day grappling with how we in New York State can more quickly implement new models of primary care that could change the way patients in New York experience health care. As more people gain health insurance coverage, and as the health care system looks to save money and emphasize keeping people healthy (not just treating them once they're sick), primary care is becoming more important than ever.

The meeting was sponsored by three New York organizations that play key roles in shaping our State's health system: the United Hospital Fund, the Primary Care Development Corporation and the New York chapter of the American College of Physicians. They invited physicians and other leaders of large and small organizations that provide primary care, health insurance payers (including insurers and employers) and State government officials to share ideas about how an energized primary care system could create a better day-to-day health care experience for patients and eventually lower health care costs.

One thing that made the meeting productive (and hopeful!) was a shared sense of goals for our State among these diverse players. Consensus surely supported the need for a larger role (and more resources) for primary care and payment reform that makes health care both more responsive to patients' needs and more affordable. And just last week, the New York State Department of Health released a draft plan for supporting advanced primary care in New York State. The plan sets out to do much of what we discussed at the meeting: achieving the "triple aim" of improved health, better health care quality and consumer experience and lower costs.

Four main themes stood out:

  1. We only spend about 5 percent of health care expenditures on primary care today. The overwhelming share of health care dollars go to hospitals that work to repair people who do not get the type of primary care that can solve health problems early and avoid high-cost health care. What if we increased spending on primary care by, say, 40 percent? That would only raise health care costs by 2 percentage points. Taking a long view, we know that investing in good primary care will save much more than 2 percent of the high-cost services like hospital care and emergency room care. Rebalancing our health care spending to support more primary care is better for both our health and our wallets.

  • We often think that the important role an expanded primary care system can play is to reduce the flow of patients to specialty and acute care by helping people understand when they need the sophisticated care provided by hospitals and specialists (and when they don't). But, primary care providers themselves (both physicians and the various care managers who are key to modern primary care) emphasize two things. First, they can probably be more effective by helping people to avoid health problems through lifestyle changes and preventive services, rather than by only guiding their patients to hospitals and specialists once they're really sick. Second, those health care providers need better information and more care management tools to be effective at better guiding patients in using the rest of the health care system.

  • It is crucial to get as many health care payers as possible to coordinate their approach for paying primary care providers in ways that encourage expanded roles for primary care. Right now, each insurance company, the State Medicaid program and the federal Medicare program all try to encourage expanded primary care that keeps patients healthy, but the incentives they use often are conflicting. Providers need clear rules about what payments they will receive when they deliver more extensive services to patients in their offices. This approach has been tried in the Adirondacks region of New York State and early indicators are that it is working.

  • All of this "system change" is crucial if we want our State to have affordable, better quality health care. But it is going to be difficult to really make it happen, and it will involve an expensive transformation process. Both primary care providers and providers of acute and specialty care need to reorganize how they relate to one another and how they integrate their services with one another. They need to devise new methods for compensating the many professionals who deliver care to people. They need to learn how to share risk with payers so that everyone has the correct incentives to provide effective care and efficient care.

    • A key first step to meet the challenge of systems change is understanding how we can make the investments that are required and learn the new approaches to care that are necessary but still do our "day jobs" of caring for people day in and day out. Other American industries have successfully transformed themselves on the go; we in health care need to learn from those successes.

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