Forging a Social Movement to Dismantle Entrenched Power and Liberate Primary Care as a Common Good

I greatly appreciate the thoughtful and informative eLetters about my article. I know many people share the pessimism expressed by Drs. Saver and Antonucci about meaningful beneficial changes ever coming to primary care. The longstanding barriers and entrenched interests are formidable. But as Drs. Green and Fish articulate in their powerful letters, we can muster our resolve and faith in times of hardship and look for stars in the darkness of midnight to find a way forward and not succumb to defeatism. It has been said that hope and optimism are different concepts. Optimism is a judgment of what is likely to happen, and hope a conviction of what must happen. I remain hopeful if not always optimistic.
I appreciate Dr. Halloran's solidarity as a psychologist deeply involved in family medicine practice and education, and her note of hope.
Dr. Gill share's extremely important lessons from his deep experience in state level policy change on primary care spend in Delaware. Critically, he highlights the limitations of a state level policy that only affects about 10% of overall insurance payments and beneficiaries due to excluding Medicare and Medicaid and self-insured employer based plans. This is one reason that I propose a unified financing system for primary care so that an increase in primary care spend would apply to the entire health care budget and not just a small slice. In California, state Senator Scott Wiener has introduced SB770, instructing the state set a timeline for negotiation with the Federal Government to incorporate federal funding of Medicare and Medicaid into a state based single payer program for all Californians. Maryland is an example of a state that has obtained federal waivers to permit an all-payer model that is another approach to overcoming the limitations Dr Gill describes.
Sometimes it can feel like 2 steps forward, 1 step backwards (or 1.75 steps backwards). But I hope we can channel the energy of family physicians, other primary care workers, and patients and the public to keep marching forward, despite the obstacles in our way.

I was excited to read Kevin Grumbach’s article in Annals entitled “Forging a Social Movement to Dismantle Entrenched Power and Liberate Primary Care as a Common Good”. I completely agree that primary care is a common good and that “Market-driven medicine has been inimical to primary care as a common good.” I love the concept of the “Primary Care for All” model. I agree with Kevin that starting at state level could stimulate incremental change to move toward this model. So I’d like to share some of the experiences in our state of Delaware, and would be interested in hearing the experience of others.
I have been the physician lead in our state’s primary care reform efforts over the past seven or eight years. We had been one of the worst states in region with regard to access to primary care, largely due to the fact that we were one of the worst in the country with payment for primary care. We also had one of the highest overall costs of care in the country, partly because of poor access to primary care but also because of enormous overpayments to our hospital systems.
We followed in the footsteps of Rhode Island and Oregon with primary care reform, first getting legislation passed five years ago to require payments for primary care services be at least at Medicare rates (yes, it is sad that this represented a tremendous improvement) and then two years ago getting legislation passed to require a minimum spend on primary care (increasing from the baseline of four percent gradually to 11.5 percent of overall spend, with the goal of moving toward a capitated model). This was despite the strong opposition from the payers and the hospital associations (partly because the 2nd bill also required a slowing of the dramatic increase in payment for hospital services). Our experience with this opposition certainly illustrates Kevin Grumbach’s statements that “Reason, as Starr notes, often collides with power”, and that “Power doesn’t willingly relinquish itself.” I have appreciated help from national family medicine leaders such as Bob Phillips, Andrew Bazemore and Jack Westfall in providing us with some of the data needed to push this legislation over the finish line.
But despite the seeming victory for “primary care as a common good” in our state, we discovered that the impact has been very small and the challenges much greater than we thought. The first challenge is that state law does not apply to Medicare, Medicare Advantage, or any self-insured employers. It can be applied to Medicaid, but our state Medicaid resisted participation and so were not included in the legislation. This left us with the law applying only to 10 percent of the population at best. I would be interested to hear how others have dealt with the “ERISA-exempt” problem that leaves 70-80 percent of commercially insured out of the purview of state laws. Without much broader participation, state laws will do little to move us toward primary care for all.
A second challenge has been the façade of “value-based care”. While no one can argue that any health care should have “value”, in reality value is almost never measured in a way that has anything to do with value. Payers measure value in ways that require enormous administrative burden to already overburdened primary care clinicians, such as checking boxes and submitting CPT2 codes for data on BMI and blood pressure that already exist in the EHR. There have been important initiatives to measure value appropriately, such as The Center for Professionalism & Value in Health Care’s “Measures that Matter”. These focus on true measures of value in primary care, such as access, comprehensiveness and coordination. But these measures are not used by payers (certainly not in our state). Instead, payers use the “value-based” mantra as a mechanism to avoid payments when clinicians fail to meet their administrative burdens.
While the experience in our state has been disappointing and frustrating, I am heartened by Kevin’s call to engage patients and the community in our efforts. I agree that “Family physicians and their organizations must forge authentic partnerships with allies. Principal among these should be patients and community members.” I think we are past the time of thinking that our partners are payers and hospital systems that benefit from the status quo and have little interest in the common good. I will be engaging with our state medical organizations and policy makers to move in this direction. And I would be interested in hearing others’ experiences and plan along that vein.

Kevin Grumbach, MD, has provided us with a clear-eyed view of our brutal current reality, our prior failures to improve our lot, and our need to pivot toward & embrace our patients and communities as allies in overcoming decades of discrimination and under-resourcing of family & primary care. In truth, we are not serving our patients and communities well by allowing powerful players to reduce investment in primary care while unleashing rhetorical flourishes about the value of advanced primary care. We have re-packaged team-based primary care in so many ways over the decades---yet most practices likely have fewer other professionals working in them than we did in the 1980's as reimbursement shrinks and productivity demands increase with only the primary care physician's actions leading to reimbursement in most instances.
We are clearly at the Midnight hour as Martin Luther King, Jr taught us...the hour of darkness, confusion, doubt, and despair. Yet MLK also taught us that it is only in darkness that the stars can be seen. He also made clear that it is darkest just before the dawn---that when our doubts and fears are greatest, next comes the rising sun for us to begin again.
Dr. Grumbach has provided us with a new vision of counterculture professionalism---a collective call to action to forge a new pathway and relationship with our patients and communities...not just as those we seek to serve, but as impactful and inspiring allies seeking health equity and access to high-quality, team-based primary care for each and every person across our vast and wealthy nation.
Thank you Dr. Grumbach and thanks to Annals for publishing !

I cannot disagree with anything Dr. Grumbach says here, except for being more pessimistic that taking more activist approach and working with instead of fighting against our allies in primary care has a chance of changing the sorry state of affairs. I did not imagine, at the start of my career in family medicine, that at the point I am at now, having just (mostly) retired, we would still have a system that excluded so many from coverage and yielded such poor outcomes at such high costs. But the continued discrepancies in payment for cognitive vs. procedural services do not seem to be going away. We continue with our quasi-religious belief in the value of "competition" among insurers. Having just spent a week trying to figure out my options for enrolling in Medicare, as someone who understands the issues likely better than 99.9% of Americans, I was stunned at how difficult it try to make an "informed" choice. And why should costs of Medigap plans from different insurers that, by law, have to have exactly the same coverage, vary by as much as $30-$40/month? Clearly, insurers understand that most Americans cannot sort through this and make ill-informed choices that will cost them more and yield higher profits. The clinic where my wife and I received primary care was bought by an arm of a for-profit insurer and it is no longer possible to reach a human by phone. I tried to reach the urologist on call for our hospital about an acute patient issue several weeks ago. He worked for that clinic. As a physician trying to reach another physician, I spent over an hour on hold and never got to a live person.

Private equity firms are taking a larger and larger role in practice ownership. Their goal is extraction of maximum profit, not improving patient care. Many of our large, non-profit health care systems, as highlighted recently in a series of articles in the New York Times, may not be distributing profits to shareholders, but are accumulating large funds being used as venture capital and pursuing payment from people who cannot afford to pay as well as paying their executives handsomely. Many Americans, disproportionately minorities and the poor, are mired in medical debt. Tinkering with the RBRVS is unlikely to either dramatically change how valued primary care is in our system nor how attractive it is as a career choice to trainees.

Insurance companies add huge overhead costs to our system for no added value. Those I work with and I have wasted untold hours dealing with inappropriate denials of care (with physicians employed by insurance companies denying hundreds of thousands of claims without even looking at them [e.g., https://ctmirror.org/2023/03/25/how-ct-based-cigna-saves-millions-doctor...), multiple and often unknowable formularies/copays/exclusions for medications, etc. Medicare Advantage, rather than decreasing costs via competition, is costing us more than traditional Medicare would. In my entire career, I can think of exactly once where "input" from an insurer actually improved care. A single-payer, capitated system of care would instantly save the U.S. a huge amount of money by eliminating not just their overhead but ours as well for dealing with them. Yes, such a system would also have problems, but they would be far less wasteful and discriminatory than the system we have now.

Alas, I think it will take far more than the type of activism and new alliances Dr. Grumbach proposes to bring about meaningful change of the type he advocates and we so desperately need. I wish I had a good solution to suggest, but we seem no more able to address this sensibly than other foreseeable catastrophes that could be avoided with major systemic change, such as global climate change and the likelihood of more pandemics. . In a country where politicians in 10 states who refuse to expand Medicaid coverage when the federal government will pay at least 90% of the cost do not get ridden out of town on a rail, true reform of of the medical-industrial complex will likely require much stronger political action than somewhat broader alliances and patient testimonials. Nationwide primary care stoppages? Discharging politicians opposed to reforms from practices and telling them they can go to the ED if they need care? We need to get more creative in addition to the very sensible measures Dr. Grumbach suggests.