Primary care must evolve to survive

Firefly’s Chief Clinical Advisor Andy Ellner¹ and Vice President of Clinical Nisha Basu², along with Harvard Medical School’s Applebaum Professor of Medicine Russell S. Phillips³, recently published From Revolution to Evolution: Early Experience with Virtual-First, Outcomes-Based Primary Care in the Journal of General Internal Medicine. 

Rather than cover primary care’s shortcomings from a patient perspective, the article shifts the lens to examine how the very structure of primary care harms physicians and threatens its own future. 

Drawing on nearly two decades of research findings, the article establishes a blueprint for how primary care can evolve to address issues facing both physicians and patients. The care model they propose is at the heart of everything we do at Firefly. Here, we offer a distillation of the article’s most salient points as we look under the hood at what makes the model necessary and compelling. 

The current state of primary care

Primary care is not immune to the ills that burden the broader healthcare system. It’s inefficient, inconvenient, and often inaccessible, optimized neither for patient experience nor positive outcomes. 

Consider the impact on health professionals and the situation looks even more dire. Outdated approaches to care, administration, payment, and technology are not merely burdensome. They actively contribute to physician burnout and dissuade students from entering the field. COVID exacerbated these issues with added financial pressure and nearly unimaginable stress. It’s no wonder physicians currently seek care for anxiety and depression in record numbers. They also have higher rates of suicide than the general population.

“Depression often comes from a sense of the powerlessness we have to change a system in which we don't feel valued.” 

-Dr. Russell S. Phillips

Yet, the case for primary care as the foundation for high-value, high-quality healthcare has never been stronger, with life expectancy higher by nearly a full year in areas with more primary care physicians (PCPs). Primary care’s value is undisputed, but its current trajectory is unsustainable. 

Flaws in the structure of primary care

PCPs are expected to meet the demands of both synchronous and asynchronous care along with mountains of administrative work. They’re trapped in a fee-for-service (FFS) system driven by payment, scheduling, and workflow software designed for revenue management. Let that sink in. The daily routines of the physicians at the foundation of our healthcare system are driven not by outcomes or value, but by revenue management. 

That means a PCP’s days are packed with visits from patients who often require neither a physician nor an in-person visit. Despite receiving unique training to handle complex conditions, PCPs have less time than ever to see patients who need them most. This frustrates physicians and patients alike and leads to patients seeking care in expensive and inconvenient settings like emergency rooms. 

A proper fix for primary care requires more than tinkering. It calls for a clear, evidence-based restructuring centered on value, outcomes, and engagement that simultaneously:

• Addresses clinician burnout
• Delivers improved outcomes and a better patient experience
• Lowers costs
• Improves access and equity

The way forward

Pulling from years of primary care research, Ellner, Basu, and Phillips propose that primary care reorient itself to be:

• Team-based with clearly defined roles and workflows
• Outcomes-driven, measured in terms of efficacy, cost, and satisfaction (for physicians and patients) 
• Virtual-first, leveraging readily available technology for greater efficiency 

How would this look? Consider a primary care team where:

• Nurses triage patients via email, chat, and phone and intelligently route them to optimal care options
• Nurse practitioners (NPs) and physician assistants (PAs) provide most care for common conditions and serve as continuous contacts for patients
• Physicians guide NPs and PAs, manage patients with complex conditions, and focus on building trust and rapport 
• Behavioral health specialists work in concert with the team, delivering short-term therapy and guidance to long-term solutions as needed
• Health coaches provide ongoing lifestyle support
• Pharmacists assist with medications and safety reviews
• Care guides coordinate care and navigate to specialists

In other words, everyone coordinates care around the patient while working at the top of their license or skillset. This not only delivers more effective, efficient, and accessible care, but supports clinicians in rediscovering the fulfillment — and dare we say joy — that drove them to primary care in the first place. 

Evolved primary care delivery

Perhaps the biggest change in this restructuring is that the “doctor visit” is no longer the focal point for all care. Instead, care teams have clearly defined roles and supporting technology, like patient relationship management software, that allows them to efficiently provide care for how people actually live and work. They have, for instance, dedicated time for asynchronous care like creating care plans, consulting with remote specialists, and responding to patient chat messages, emails, and phone calls.

With planned asynchronous care and proper staffing, teams are empowered to respond quickly and frequently, establishing more opportunity for patient engagement and trust building. This has a secondary effect of reinforcing a simple and powerful idea: patients should reach out for care whenever, wherever they need it. The convenience of it all (a chat message returned within minutes vs. a visit 3 weeks out) means fewer patients ignoring their needs or self-triaging only to end up in the ER.

“We also know that strong relationships with patients leads to both trust and empathy, which feels personally rewarding, but also contributes to the maintenance of continuous relationships where patients rely on you, and your team, to be there for them in times of need."

-Dr. Russell S. Phillips

Note too, that with NPs and PAs at the center of the care team, doctors can provide high-quality, continuous care to larger patient panels. With the shift to asynchronous care and automated data collection, teams can also create standard templates for condition management that become part of evidence-based clinical workflows. 

The big question: will it work?

Research points to a resounding “yes.” Dedicated time for synchronous and asynchronous care, well-coordinated teams, and supportive technology enable clinicians to finish tasks and documentation during work hours. Plus, giving physicians agency, collaborative support, and clear avenues to quality improvement has been shown to reduce burnout and keep them working in fulfilling primary care positions for longer. 

Outcomes-based care also holds tremendous potential for reducing health disparities. By tracking clinical outcomes, teams can respond to gaps in care both within populations and between populations. And care that takes advantage of expanding broadband availability removes access issues for people who live in rural areas, struggle to leave their homes, or have challenging work schedules. 

The traditional in-person visit has built-in pressures on both physicians and patients. Shifting toward a more flexible, empowering care model grants clinicians the time to consult the literature and colleagues on complex cases. Likewise, patients can process difficult decisions in their homes and communities, reaching out to care teams over chat for continuous support. 

This new model — a partnership across time, space, and clinical disciplines — allows physicians and patients to celebrate the challenges and wins together. In the process, it offers more human moments that spark joy in the practice of primary care.

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Note: See the full article to dive deeper and see complete references for claims made in this post. 

1. Andy Ellner, MD, MSc is Co-founder and Chief Clinical Advisor at Firefly Health.
2. Nisha Basu, MD, MPH is Vice President, Clinical at Firefly Health.
3. Russell S. Phillips is the Applebaum Professor of Medicine, Professor of Global Health and Social Medicine, and Founding Director of the Center for Primary Care, all at Harvard Medical School.