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March 29, 2017

This doctor changed Atul Gawande's mind on primary care. Will he change yours?

Daily Briefing

    Editor's note: This story was updated on July 10, 2018.

    The Daily Briefing's Josh Zeitlin spoke with Asaf Bitton, an internist and assistant professor at Harvard Medical School and Brigham and Women's Hospital, about what his fellow doctors get wrong about primary care, his debates with surgeon and author Atul Gawande, and more.

    The interview, which took place shortly after Gawande credited Bitton in a New Yorker piece with changing his views on primary care, has been edited for clarity.

    “I made the mistake of saying that I had more opportunities [as a surgeon] to make a clear difference in people's lives. He was having none of it ... I finally had to submit. Primary care, it seemed, does a lot of good for people—maybe even more good, in the long run, than I will as a surgeon.”
    Surgeon Atul Gawande on Asaf Bitton in the New Yorker

    Q: In his New Yorker piece, Dr. Gawande writes about his transformation in how he views primary care—how he's grown to view a lack of focus on primary care as a "medical emergency." How widespread do you think misconceptions about primary care are in the industry?

    Asaf Bitton: I think that there's generally not a nuanced and sophisticated enough view of what primary care offers. There's unfortunately this conception that primary care is about simple office visits for simple problems, and that's actually not the case.

    Asaf Bitton, assistant professor, Harvard Medical School and Brigham and Women's Hospital

    Primary care, when done well, is a method of care that basically offers valuable core functions for people and health systems. It offers first-contact access, it offers coordination, it offers continuity, it offers comprehensiveness, and it offers a whole-person approach. These functions are complex and deeply valuable to people. So when we reduce the production of these functions to just their most simplistic form—an in-person visit—which is obviously not all that primary care does, we lose some of the value and enter this spiral of misunderstanding and improper compensation

    People sometimes say about the concerns primary care providers raise, 'Oh, this is just about the underpaid doctors trying to get more from the overpaid doctors.' That really couldn't be farther from the truth. It's really about aligning a payment system toward our end outcomes and goals.

    If you want a system that produces population health, that addresses those key functions, including providing a safe, patient-centered system, you have to have a robust primary care foundation. And when you pay only for short visits and don't incentivize much else, then it's really imbalanced.

    When primary care encompasses only between 3 to 6 percent of overall U.S. health care spend, there's a deep imbalance within the system, in terms of payment, workforce, and system orientation. Medical students with huge debt tend to go into specialties that are better compensated, which are also those that they perceive to be higher on the totem pole. And that's unfortunate.

    Q: So in your ideal world, what percentage of U.S. health care spending would go toward primary care?

    Bitton: I do a lot of research at Ariadne Labs on global primary care systems that work. We work with a global partnership convened by the Bill and Melinda Gates Foundation, World Bank, and the World Health Organization called the Primary Health Care Performance Initiative to measure and improve primary care performance globally. What we find is that health care systems that have between 10 and 20 percent of their total health care spend on primary care tend to have much more robust primary care systems and better overall outcomes.

    So we're not talking about massive shifts or massive changes in the distribution of health care financing. What we're talking about is adequately funding what are thought to be common population, societal, and political goals. Primary care is something that almost everybody wants, but also takes for granted.

    Q: Is the shift to value-based care starting to make the compensation landscape better for PCPs? If so, to what degree?

    Bitton: These value-based care experiments are all trying to ask the question, 'How do we move from counting discrete units of limited interaction to encompassing the broad array of ways in which care teams can improve health for patients?'

    We're starting to see a lot of activity across the whole payer landscape around these issues, and a lot of testing in federal, state, and private markets. Just look at large multi-payer efforts like the Comprehensive Primary Care Plus initiative in 14 states, with 3,000 practices serving nearly 2 million Medicare beneficiaries. It provides a different, non-visit based payment method linked to changes in the way practices deliver care and uses data to improve performance.

    Personally speaking, as a physician and as someone who cares a lot about primary care, I think the shift to more value-based care can't come fast enough, and it could be accelerated even more. I think we really hobble our society's ability to get the most out of primary care by just thinking about the payment side of it in such overly simple terms as counting visits and minor office procedures.

    The corollary is that we know from very good, published evidence across the world that those countries and regions that have health systems that are oriented toward primary care provide the best outcomes at relatively efficient costs. The evidence is there.

    Q: Do you see primary care physicians as inevitably approaching care with a different perspective than specialists? Or are there some aspects of medicine that specialists should learn from PCPs, and vice-versa?

    Bitton: I think that the primary/specialty care divide in American medicine is sometimes overemphasized. There's nothing completely unique to the skills and disposition of primary care providers. There are many specialists who have excellent communication skills, practice effective coordination, have relationships over time, and prioritize being accessible to patients.

    Primary care is where it all comes together, in terms of being able to offer really important longitudinal relationships to people over the course of their lives for the majority of care needs, the majority of time.

    That's important, but there are also a lot of specialists who do a lot of chronic disease work and have great relationships with patients. So I'd be careful not to emphasize the provider differences. What I would emphasize is that as a health care system, there are a lot of functions that primary care offers that you really want to deliver more consistently in order to achieve your goals. Primary care can help you do that efficiently and effectively.

    Q: Other than payment systems, what else needs to change for primary care to thrive more going forward?

    Bitton: What's really important for primary care to achieve its top-level goals is better data exchange between hospitals, specialists, and primary care. It's still way too hard between systems, within the massive fragmentation of American health care, to get timely transfer of information about transitions of care and updates to care plans when people go to their different specialists or facilities. It's even harder to get aggregated performance data from a variety of data sources like EHRs and claims in order to track and improve overall trends in care.

    It's also important for primary care to look hard at itself and think about the best way to transform its practice of medicine. We need to have an honest conversation about the best ways to move from a reactive model of individual clinicians spending all of their time seeing patients who walk through the door to a more dynamic team-based model of care that includes visits and population health promotion.

    Primary care has become complex enough that in most cases it's offered really well through teams. So practices need to start thinking about how they take care of defined populations of patients who are empaneled to them, meaning they have a panel of a certain number of patients they're responsible for reaching out to even if they don't come in for a visit on a given day.

    That takes teams, that takes effort, that takes a different way of doing business, and that also takes a different payment model to reward all those activities that don't and can't happen just during a visit.

    Q: Did you think you changed Dr. Gawande's mind on primary care, when he went from saying that he as a surgeon "had more opportunities to make a clear difference in people's lives" than you to acknowledging that primary care does "maybe even more good, in the long run, than" he will do as a surgeon?

    Bitton: I think you'd have to ask him that, but it was a year and a half long set of many conversations, visits, debates, and spirited discussions. And at end of the day, I think we see much more eye-to-eye than we did at the beginning. And if I helped in that process, then that's fantastic. I wouldn't take credit for it, but I'm happy to have contributed if it happened.

    Q: Has being mentioned in Dr. Gawande's New Yorker article changed anything for you? Have your patients said anything?

    Bitton: I've definitely heard from some of my patients that read the article. Sometimes patients don't know, when you're in academics like me, that you have this other side to your work. The reach of the New Yorker is amazing—people from high school and summer camp reached out to me who I haven't heard from in 25 years.

    People have been by and large positive about the article, saying for example, 'That really expressed why I feel so strongly about having a regular source of primary care.' Atul, as a surgeon, went through this journey of trying to understand what is intrinsically valuable and distinct about primary care, and he articulated something that really resonated with a bunch of people.

    Q: Anything you'd like to add about the future of primary care?

    Bitton: I'd just say that I think the future is mostly bright. I think there are major challenges ahead with uncertainty about the future of the ACA, as well as known workforce and payment hurdles.

    There is also an important and healthy debate about how best to transform primary care delivery—it's clear it won't be delivered in just one way. There will continue to be a team-based, small independent practice medical home route of reform. There are certainly a lot of innovations around telemedicine and other mobile health companies coming into this space with what will be necessary innovations around access to non-face-to-face care. There's a robust federally qualified health center and community health center set of models that will continue to expand, as well as the VA primary care model that offer a lot of insights. And there will be urgent care centers and concierge models that fill in gaps in the delivery of core functions like access and comprehensiveness.

    So there's no one-size-fits-all solution to this, but in all that heterogeneity you find a lot of innovation and progress. There are shared principles of team-based care, financing that matches the end goals, and a recognition that primary care is a lot more than sore throats and blood pressure checks – it's about integrated care for the whole person in their community. And that recognition would be good for providers and patients alike to consider as we figure out the best ways to improve our health system.

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