The Four Cs: The Balance of Robust Primary Care
What do healthcare consumers need from primary care?
That’s a question many healthcare industry leaders are asking. While the question itself is fairly simple, it’s challenging to adequately address. There are many ideas and strategies surrounding this topic, but my goal here is to describe the critical need for balance among the four elements essential to the creation and sustainability of a robust primary care system.
We can easily visualize this need for balance by imagining the four legs of a table. If one is weaker, shorter than the others, or missing, the table will be unstable at best and nonfunctional at worst. Today’s American primary care system is somewhere between the two alternatives, but sadly we see lack of function more often than not.
Our society desperately needs the healthcare system to achieve the Triple Aim for improved population health, better individual wellness and more affordable care that won’t cripple the economy. Strong, effective primary care is the only route to get us there, but with our present imbalance the Triple Aim is impossible.
So let’s take a look at the four legs of the table—“The Four Cs”—that must be in balance for our primary care system to thrive.
The first essential element is a patient’s long term, continuous, personal relationship with a provider. This gives the provider a good knowledge base of the patient and the circumstances of his or her life, personality and medical history—all of which have an impact on health. This understanding of the patient’s personal life, in addition to the mutual trust that develops over time between the provider and patient, improves the provider’s decisions and facilitates more effective communication.
A healthy provider/patient relationship also leads to increased patient engagement. Engagement is vital because no matter how excellent care is, there will be little lasting impact to health if the patient is unmotivated and uninvolved.
Competent decision making is the second essential element and the strongest of the four legs in our primary care system’s current state.
A new emphasis on laboratory research developed with the advent of modern medicine in the late 1800s and beginning of the 20th century. The scientific approach to medicine became the norm, leading to what is now known as “evidence-based medicine.” This knowledge grounded in research has become the curriculum for medical schools.
Physicians in the US receive 7–10 years of medical education and training following their undergraduate degrees. We’re fortunate as a nation to have some of the best healthcare education in the world—particularly the training of comprehensivists who can address patients’ health with a whole-person orientation. The high level of training and expertise of comprehensivists, along with important interventions such as medications, imaging and labs, have created a primary care environment in which most patients have very successful outcomes.
Of all the disciplines of medicine, primary care is the most affordable. But this element of cost effectiveness isn’t utilized as much as it could or should be because of the lack of convenience (more on that aspect to follow in a moment). Personal knowledge of the patient—an attribute best developed within primary care—helps the provider avoid unnecessary tests or treatments, which can lead to significant savings for both the patient and society as a whole. And ongoing chronic care management lowers the risk of needing costly interventions later when a neglected disease becomes more severe.
Many consumers’ attitudes toward healthcare reflects the belief that no amount of money is equal to health. With that perspective, going to an urgent care center or the ER is a satisfactory alternative to seeing a personal provider. But it has gotten our society into trouble because we’ve devoted a tremendous amount of money to interventions that haven’t actually contributed to positive health outcomes.
Studies show that patients who see the same provider on a long-term basis have fewer ER and hospital admissions, have better control of chronic diseases (like diabetes, hypertension and asthma), live longer and cost the healthcare system less. Seeing a “familiar physician” is the most important thing a person can do for his or her health—and it’s the key to sustaining a cost-effective healthcare system.
Convenient access, the fourth element of robust primary care, is the leg that’s most often missing from the table. When access is poor, it doesn’t matter how much expertise the provider has, how strong the provider/patient relationship is, or how cost effective primary care is. If the provider isn’t available when care is needed, he or she offers essentially no value to the patient.
Because of this lack in primary care, we’ve seen the development of an industry of urgent care centers and minute clinics for the singular purpose of convenient access. This convenience has often come, however, at the sacrifice of cost effectiveness and comprehensive, relationship-based care, the context in which the best provider decisions can be made. We’ve also seen the use of Emergency Rooms change due to the lack of primary care access. Now every ER regularly deals with a high number of non-emergency issues at inappropriate costs to the patient or the payer, driving up overall healthcare costs.
If primary care is going to become a viable option for accessible care, practice hours must adapt. This is where innovation is needed, because practices need to be open 12 hours Monday-Friday and at least 6-8 hours on weekends. Sickness has no timetable, and patients need access seven days a week—for the sake of their health, work schedules, expense and positive outcomes. And contrary to popular opinion, it’s possible to do this in ways that not only open up patient access, but also enhance the provider/patient relationship and protect the work/life balance of providers.ncy issues at inappropriate costs to the patient or the payer, driving up overall healthcare costs.
A promising future
Primary care may be struggling, but it’s far from irrelevant. As we look at strategies to design a robust primary care system that meets the needs of our society, we must ensure these “Four Cs”—continuous, competent, cost effective and convenient—become intrinsic attributes of our primary care delivery.
The thriving primary care system we envision is still in the distance, but we can’t stop short. Now more than ever we must bring the essential elements of robust primary care into balance so we can offer the kind of care our patients need and deserve.