The Destruction of Primary Care

Guest post by Edgar T. Wilson.

Edgar Wilson

Economists, especially today, like to talk about creative destruction.

Schumpeter considered it the “essential fact about capitalism,” that things have to fall apart so better things can take their place. The familiar is violently displaced by the unfamiliar, but superior, alternative.

Buggy whip makers are sent out of business as car makers take over the transportation space. Typists go extinct as word processing becomes cheap and ubiquitous. Blockbuster goes bankrupt, so Netflix and all its streaming peers can take over the space. The notion that the New can mean bad news for the Old is nothing unique to our modern era, though perhaps the speed and distribution of change thanks to globalization and digital technology means we see this more and more.

Well, 2017 may well be the beginning of the end for primary care as we once knew it.

The “Who’s on First” of Healthcare

As with any other example of creative destruction, the signs in primary care have been there for anyone to read, though perhaps the conclusion they point to hasn’t been quite as clear as the contributing forces.

Nursing, as a profession, has been on a long arc over the last century or so, transforming patient care as well as clinical organization and even leadership. Nurses have evolved from subordinates to doctors to, in some cases, replacements–notably, in primary care clinics, especially critical access hospitals or in areas where patients might not otherwise get to see a doctor outside of an emergency room.

Primary care provider shortages aren’t strictly limited to rural or remote areas. Thanks to demographic trends, more people are living longer and managing more chronic conditions. Keeping this swell of aging patients from charging into Emergency Departments en masse was part of the logic behind elements of the Affordable Care Act shifting resources to clinics run by NPs as opposed to MDs. While nurses face a shortage of their own, they have still been tagged as a key element of preserving and expanding access to primary care. In 2007, the shift in nursing toward a more central leadership role was codified by the Association of Colleges of Nursing with its designation of the Clinical Nurse Leader as a new official role for nursing professionals.

Simply put, consistent access to primary care supports prevention strategies, which are altogether cheaper and more effective than sending everyone through an ED or into a long-term care clinic. While many–notably, the American Academy of Family Physicians and the American Medical Association–muckrake over this disruption of scope of practice, the change is one of necessity. Nurses today provide critical care, and lead diverse clinical and professional teams to coordinate whole-person health.

With or without the Affordable Care Act, the shortage in primary care will persist. Expanded access through insurance only exacerbated the underlying issue. As Millennials enter middle ages and Boomers carry on retiring and living longer than ever, primary care will be stretched. Whatever comes out of the Trump administration or the ongoing scope of practice debates, primary care requires providers, and nurses are showing up to work.

Primary care is no longer the sole domain of physicians. Supply and demand, meet creative destruction.

Prevented from Progress

A major force of disruption–and ultimately, creative destruction–is the shifting status of preventive care. Again, prevention saves money; there is no politicizing the reality that beyond Obamacare or any other snappily-monogramed law, keeping people healthy is cheaper than restoring them to health after illness. Qualitative measures of care, expanding access, and the role of nurses and caregiving professionals, all intersect where prevention becomes a priority.

But prevention is not as simple as the annual check-up or reminders to eat better and exercise more. Wellness can seem all but impossible in a culture that contradicts good health habits or ignores the extent to which genetic variability and  financial class membership obfuscate seemingly simple choices like what to eat or where to work. Real prevention, that actually works to reduce costs and spending on healthcare, is shifting to focus on the social determinants of health.

A major area of contention in redefining (and conceptualizing delivery) of primary care is reproductive and otherwise gendered care. We have major progress to make in fully connecting poverty, race, geography, or education with health. But the void is even more stark than even that: rather than taking it for granted, advocates still have to make an argument that women’s health matters. Gender is, and always has been, a key social determinant of health, whether in the third world or the United States.

In the wake of President Trump’s inauguration, we saw a vivid reminder that prevention lacks equity along gender lines. As a society, we have yet to agree on just what ought to be considered “basic” levels of preventive care with respect to family planning, or even feminine hygiene.

Resolving this is going to be one of the major popular movements of the modern generation, and that is going to have repercussions for how we conceive, package, deliver, and pay for primary care.

As with the fate of the ACA, even if the issue of abortion is legally settled for now and ever, the reasonable provision of women’s healthcare remains a critical issue only destined for greater emphasis, visibility, and public discussion.

Mind the Gap

Finally, there is the longtime challenger, mental health. This core determinant of health has made its presence felt, if not recognized, everywhere: there is a correspondence between poverty and mental illness; in children, it can be permanent, whether their American Dream is realized or not. There are correlations between gender, inequality, and depression and anxiety. There is compelling evidence that our current opioid epidemic is largely a social phenomenon, with lower population density correlating with higher rates of overdose deaths and addiction.

For patients regularly seeing caregivers, the effects of stress can still be missed and left to manifest physically, wrecking personal health from the inside-out. Even the seemingly well-off are not immune to the creep of mental illness and its infectious influence. Every single element of American society has serious, measurable consequences for the mental wellness of its citizenry, yet it remains routinely neglected in primary health, and in healthcare at large. Neglect of emotional wellbeing is so entrenched that even those on the frontlines of giving service and attention to the most neglected and vulnerable segments of society have to be reminded to take care of themselves, lest they lose the ability to care for others.

The very technology heralded as transformative for the healthcare industry has managed to mostly ignore the need to incorporate mental health and behavioral health data as an essential feature. While we struggle to make our EHRs work to their fullest potential, we remain compartmentalized in our delivery of care, to the exclusion of mental health data.

Primetime

What this all amounts to is not a purge of primary care, or even severing the sacred doctor-patient relationship that so many physicians want to see restored to its place of primacy in healthcare. Primary care is at the inflection point where all these issues, controversies, awakenings, and political agendas will be reconciled.

Primary care is where patient relationships with caregivers begin. It is the single most important realm for gathering data, whether in support of high-level research or to connect providers along the continuum of care. It is the one region of our entire health system where patients feel remotely in control, where they can “shop” for the care they want before an emergency negates all agency and assumes decision-making on their behalf.

A new health future is on its way, and it will reconfigure our entire system to save money and lives–starting, as it was always meant to, with primary care.

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