Podcast Episode Transcript: When primary care fires on all cylinders

With L. Gordon Moore, MD

Dr. Gordon Moore: Welcome to 3M’s Inside Angle podcast. This is your host, Gordon Moore. With me today is Wayne B. Jonas, MD. He is a practicing family physician, an expert in integrative health and health care delivery, and a widely published scientific investigator. Dr. Jonas is the Executive Director of Integrative Health Programs at Samueli Foundation, an effort supported by Henry and Susan Samueli to increase awareness of and access to integrative health.

Additionally, Dr. Jonas is a retired Lt. Colonel in the Medical Corps of the United States Army. From 2002 through 2016, he was President and Chief Executive Officer of the Samueli Institute, a nonprofit medical research organization supporting the scientific investigation of healing processes in the areas of stress, pain, and resilience.

Welcome, Dr. Jonas.

Dr. Wayne Jonas: Thank you very much, Dr. Moore. It’s a great pleasure to be here. Thank you for having me.

Dr. Moore: I was pleased to read an article that you published recently, titled The New Model of Care to Return Holism to Family Medicine. I was thrilled, because I’ve looked at models of care delivery and I am attracted to the literature that says that a high performing primary care foundation is an essential component to a high performing health care system.

Your article describes primary care in a way, which I find very compelling and very advanced, actually, in contrast to what I actually see as the manifestation of primary care right now and I’d like to explore that and hear where this model came from and start to explore the parts of the model.

Dr. Jonas: Thank you. I appreciate that and I wrote this article because I saw, increasingly, a decline of the core aspects of what produces health out of our health care system. The data is pretty clear that our health care system is not working, if you ask the question of is it producing health and wellbeing.

The costs are going up; life expectancy is going down. Outcomes compared to other countries similar to ours—fairly wealthy countries—is getting worse, compared to most countries. Satisfaction is going down; burnout is going up and it’s just not working, actually.

One of the reasons it’s not working is because our model of care, which works tremendously to save your life or pull out a tumor or stop a heart attack or stop an infection—if there’s a treatment for it in some cases—works tremendously. That’s an acute care model; it’s a, “When you get sick, we will then fix it,” type of model. It’s a mechanical mindset. It works wonderfully when there’s an acute care problem or a mechanical issue going on.

Unfortunately, it does not work when it comes to prevention; when it comes to health promotion; when it comes to managing complex chronic illnesses over a period of time; and when it comes to disease reversal, which is possible in many cases, because it’s not set up to, nor does it address those areas.

Primary care was originally set up to try to do that. Family medicine, especially, as I write in the article, when it got the idea that we have to take care of the whole person—mind, body, and spirit. That’s the only way to actually produce health on a chronic level. It has been picked apart, over the years; it’s been funded at very poor levels, and it’s become more and more subject to a reductionistic super-specialist approach, and it’s lost its way.

The purpose of writing this article, in some ways, was to say, “Let’s look back when we knew that holism was an important way to take care of whole people, and what do we need to actually bring it into the modern age; to actually do it again, given all the slings and arrows that it’s faced over the last few decades?”

Dr. Moore: That’s fantastic. You cite in the article work from 40 years ago by George Engel, a psychiatrist who was talking about the biopsychosocial model. How does that play into this?

Dr. Jonas: George Engel, I think, created a vision for taking care of the whole person that was ground in science at the time, 40 years ago. It really was the inspiration for a more holistic look and the pioneers of specialties that emerged around that time called, “Family medicine,” which was a movement within primary care to go back to and go forward with taking care of the whole person.

It really created what now is probably the largest primary care society and efforts, family medicine, within the country. It was that kind of inspiration that brought me and many others into medicine, because we saw a way to not only treat diseases, but also to be healers and to bring the healing component—the relief of suffering and the prevention of disease and the reversal of chronic disease—into our day-to-day lives.

That inspiration was what I started the article with, because I think we need an inspiration like that. We need to return to a new paradigm in our thinking that uses an ecological mindset that pays attention to the fact that it isn’t just the body that we need to address. It’s the social and emotional and mental health issues; it’s the lifestyle and behavioral components. Fundamentally, it has to be attached to what I call, “The mental and spiritual components of a person,” that is what matters to them. We have to link up what we’re doing in health care with what people want to live for and why they live.

If our health care isn’t actually attached to that motivation and bringing them into as full partners in health care, then we end up just throwing stuff at them, with pills and procedures, straighten and trying to figure out how to get it paid for. It’s that re-envisioning that George Engel provided in that article that we need today. That’s what I was trying to do with this approach.

Dr. Moore: You were talking about my own personal evolution as early in practice, as I’m sitting there admonishing people and throwing prescriptions at them saying, “My gosh, why can’t you take your meds? Why won’t you do this? It’s in your best interest?” Then having colleagues gently, and sometimes less gently, nudge me along to understand that if I’m only treating the disease, I’m missing the picture.

Kiichiro Toyoda, the guy who was the head of the whole Toyota production system, talks about the five whys and peeling back to understand what’s beneath this. Just that biological understanding of diabetes, for instance, is insufficient unless we begin to put the head back on the body and recognize that, as people, helplessness and hopelessness trumps any prescribing plan. As we now are, with the buzzwords around social determinants to health, we’re beginning to re-recognize how much society impacts outcomes that are interesting.

You put that into this and you talk about concentric rings of practice, starting with the standard care or standard core of diagnosis, treatment, and payment. Then, you build on that. I’m fascinated by that. Tell me what you see as steps to getting to an advanced primary care model.

Dr. Jonas: The model I try to describe and illustrate in this article starts with that core standard care. Yes, diagnosis, treatment, and payment and the more whole-person model that I just taught to you actually led to a type of primary care that is the second rung. I call it, “Quality primary care.”

This is sometimes known as the Starfield model. Barbara Starfield studied this extensively and demonstrated that it could provide superior health at lower costs, if it was implemented across systems. It became an inspiration for that. It involved what was called, at the time, the four Cs. First contact, comprehensive management, coordinated care, and continuous through the lifestyle.

Out of this was inspired a new model that many primary care organizations adopted called, “The patient centered medical home,” in which they attempted to actually implement this quality primary care in those areas.

That worked very well for a while, except then things got more complex. Our knowledge base became hugely complex. The subspecialty components continued to grow; the division of the person into parts—the reductionistic approach got relentless, as I describe in there. Then the payment models began to reinforce this reductionistic approach, where you were paid for taking care of very small parts of the person, rather than the whole person.

That quality primary care model—the four C model, the primary care medical home, is inadequate, today. It does not actually produce health, either in the individual or in the population. Then, the third ring actually needs to be added to that, which I call, “Enhanced primary care.” They’re discussing this, right now, at the National Academy of Medicine, what is high quality enhanced primary care.

It brings in ways of managing this complexity even further, through chronic care models; through pharmacy services, because drugs and de-prescribing and more coordinated prescribing is needed now for anyone, as they age and develop chronic diseases.

The management of referral services. Anybody that’s had to go into the hospital and then transition out of the hospital and maintain continuity of care knows there needs to be a transition management. Then increasingly, there’s a division between mental health and physical health in this reductionistic approach. We know that we cannot take care of physical health without taking care of mental health. The incorporation of mental health is also in that rung.

Even that is not enough, if we want to enhance a population’s health and if we want to reverse the many lifestyle and behavioral types of diseases, which are the majority of things that are dealt with in the health care system, in a way that might reverse them or might heal them. Then, the fourth ring, which completes the full circle of advanced primary care involves two major areas. One, is the behavior and lifestyle and the drugless approaches that we know work, but there’s no economic incentive to actually get paid for doing. This is the element of integrative primary care.

Then, increasingly, and unfortunately with the pandemic, this has accelerated the social determinants of health—that is the social and the economic drivers that prevent people from making the kind of behavioral changes that will enhance their health or even accessing the other aspects of primary care that are in the model.

Today, if we want to really have good, high-quality primary care, we have to have all four of these rungs delivered.

Dr. Moore: I think about this, again restating that this is such an attractive model for me, because it comprehends, for me, the full scope of what I thought being a physician was going to be about. When I think about the work in this, and I would do this joyfully if I were still practicing, but I would be very nervous that I wouldn’t have the capacity to be all of these things. And I wouldn’t, necessarily, have the payment to support doing this work. What do you think about those as issues?

Dr. Jonas: That is true. Those are very relevant terms. When we go out and begin to teach practices and centers how to do this type of thing, that’s a common question in those areas. It is a challenge to do that, because of the complexity of health care right now.

There are movements within primary care that have demonstrated that it is possible to do it, even in small settings and it’s possible to do it in large settings. Direct primary care is an example of that. That’s a movement in which providers are beginning to exit the payment processes and the management process and taking them under their own roof.

They do it by making sure that they’re doing it very economically. They don’t have huge overheads, for example, and they also do it by creating teams. With allied health providers, nurses, PAs, health navigators, health coaches are very important in that area. That allow them to spend time with patients to really address them as whole people. Those are very successful.

The direct primary care movement is growing significantly, and to the surprise of many, when it first started a few years ago. Many of them are economically viable or financially viable. They’ve had to fit a square peg in a round hole of our current fee for service system, in many cases, but many of them are showing the way to do that.

Larger systems, it becomes easier to do it if they really adopt a value-based payment. That is a payment model in which they allow for the care of the whole person to occur. They invest in the care of the whole person, but they don’t necessarily, try to track every model or mechanism to do that, because they provide the flexibility for the provider and for the care team and the patient to adapt and adjust to what’s going on.

We’ve seen that, again, the COVID-19 pandemic is illustrated when systems pay for and cover whole person population care, instead of a fee for service. Even in situations like COVID-19, which has disrupted all of health care, from hospital care all the way to primary care and community care, they’ve been able to successfully manage and pay for this kind of care and take care of people.

The money is there. It’s not about being short of money, at all. We actually pay way too much for the value we’re getting in these areas. If we allow for the innovation and creativity of delivering advanced, coordinated whole person, integrative care, then many, many practices and many, many models and systems could save a significant amount of money by going upstream, addressing those underlying determinants, and engaging in prevention and disease reversal.

Dr. Moore: I’m seeing some businesses that are figuring that out and getting into that niche of aggregating the back office work for independent primary care practices, creating a kind of a care organization, so that they can contract with health plans and Medicare Advantage or others and say, “We’ll be your agents in contracting.”

I admire that, because they’re doing that back office complex work and data interface and negotiation and all that, so that the clinicians in practice can focus on the needs of the patients they serve. I don’t know that they’re going to go as far as the advanced primary care model that you describe, here. I wonder how it is we create a set of incentives that make that the clear goal and provide the resources needed to do that work.

Dr. Jonas: I think we first have to realign the metrics and say what is important. There’s been a really good description of this. The Institute for Health care Medicine developed something called, “The Triple Aim.” Now, people sometimes call it, “The Quadruple Aim,” which is can your system improve population health? Can it reduce the per capita costs? Can it deliver high quality satisfaction—a good experience including for the provider—and prevent burnout? That’s the fourth thing. The first three were the original triple aim and now, the fourth aim is making sure the provider can function and enjoy and be a healer in those areas.

Those are the metrics that need to be measured, not how many procedures have you done. Not necessarily what your A1c has done; not necessarily what the particular quality metrics that CMS needs to see. We need to realign those metrics to what matters in those areas. That’s number one.

Number two, then, we need to create a global payment model or a payment model that actually pays for the whole person and does not dictate the particular types of services that any group uses in order to create those health metrics in those areas.

We have just launched, with several other foundations around the country, a new study that the National Academy of Medicine will be doing, looking at a payment system that create health. We call it, “Health financing to create health.” They are going to be looking, over the next several months, at examples of models that work, even in the midst of the pandemic to actually enhance health and lower costs, and what those financing models look like.

I think if there’s any payers out there listening to you and they are really looking for better value in those areas, they should look for this report and look to build on that with a payment system that then does incentivize the creating of health and allows for unleashing of the innovation that our health care delivery system has the capacity to do. I think that’s one way to address those kinds of drivers that you’ve just talked about.

Dr. Moore: I’ve heard in some reports—I think Commonwealth Fund and some others—have looked at the percent of the health care dollar in the U.S., compared to OACD countries. We’re somewhere around five to seven percent of the dollar spent on primary care and OACD countries are somewhere around the 15 percent range. I know that varies—Medicare commercial and Medicaid, but it seems like we’re pretty woefully under resourcing the work.

I hear that we can reallocate resources, but that’s a takeaway from somewhere. That, to me, is going to create that pushback and pressure. How do we deal with that? How do we create a glide path, so that those who are going to have less can see their way forward in the new paradigm?

Dr. Jonas: That’s a great question. How do we create a glide path when part of that path does result in diminished returns and profits in some sectors of health care, right now? I think there’s two things important to consider, when thinking about how to do that.

Number one, yes, we need more invested in community care. We need more invested in primary care. This is very clear. If you look around to those countries that you just referred to, those that have bumped up their investment in primary care are doing better. They’re saving money in other areas. But they’re only doing it if they’re actually delivering the kind of care that we’re talking about, here—this advance primary care component. If they’re simply dumping more money into a broken system and if we end up doing that, then it isn’t going to save money. It will just continue to drive costs up.

However, what do you do if it does work; if the incentives are rightly aligned; that there is an increase in investment in high quality or advanced primary care and it begins to diminish your need for expensive specialist technology, less drugs, less procedures, etc.? That’s going to come out of a system that is now making a lot of money off of that.

I think the glide system means that we have to find a way in which reasonable costs in the financial model are still going into that kind of care, when we need it, because we do need it. People do get in accidents; they do get cancer; they do need medications and drugs in those areas; and they do need procedures.

We need to do that, but the payment system and model has to be looked at as a whole. There needs to be reasonable rewards in those areas, when needed, and we need to transition towards creating overall value so that those that are in the higher cost area actually can contribute to saving money through value-based models. They can then reap some of the rewards of that saving.

I remember an orthopedic surgical-based group that we went to take a look at as part of the Dell Medical School in Austin, Texas. Here’s a group of surgeons that, in our current system, usually makes money off of doing procedures—right knee replacements, back surgery, etc.—in a fee for service model. What they did is that they flipped it on its head and they said, “We’re going to only actually try to do what’s going to work and what’s going to produce health in this.”

They surrounded the surgical group that they ran with things that produce health and reduced the risks of unsuccessful surgeries. For example, if somebody came in and they were overweight or had diabetes, they had nutritionists and behaviorists that worked with them to reduce their weight before they did the surgery.

They could actually calculate the money they would save off of doing that than if they actually just did the knee replacement and it failed or it didn’t work without that. The same way with mental health. They brought mental health and counselors, because people that are depressed don’t do as well if they get a knee replacement, for example.

Then, they cut contracts with payers—many private payers, but also some public payers—and said, “We’ll take care of all of your musculoskeletal problems for this flat rate. If we save money and health improves, based on those metrics, we get to keep a part of that.” Guess what? They actually made money. They made more money than when they were in the fee for service area. The people contracting with them liked it, because their patients were healthier and they were paying less, overall, and their patients were more satisfied with it, because they got taken care of in a more holistic and integrative fashion.

Dr. Moore: That’s a very nice model. I’ve heard other anecdotes, if you will, of a similar nature, where capitated, certain surgeons have said, “Well, if I’m going to make the same income, I don’t need to do unnecessary procedures, to be very blunt,” and have seen significant reductions in the people who were going to the OR.

I’ve seen models—I think you’re familiar with them, as well—the Southcentral Foundation in Alaska—where the setup is that the surgeons are on salary and say, “Hey, just give me a call before you send them over, because maybe a chat on the phone is enough to say that I don’t have what they need or they should do something else, first.”

I think as soon as you start changing the financing, it changes the behavior.

Dr. Jonas: I think that’s exactly right. I’m glad you mentioned the system at the Southcentral Foundation in Alaska, because it’s a brilliant model of not only the finance changing, but they did something more challenging that gets at the heart of healing that we talked about before.

They really developed a system in which everybody in the system, from the patients—who are called “clients,” by the way, because they actually are part owners of the health care system—and the providers develop personal relationships. That doesn’t necessarily going over to somebody’s house, but it means getting to know each other as people; taking care of the social and emotional, the mental and the spiritual what matters. Getting to know that and embedding that in the process of care.

They have a whole model that they derive out of Alaskan Native culture, which creates this kind of trusting relationships between the providers and the patients. As Rebecca Etz and others have shown that the core of high-quality health care is a trusting relationship, where you feel you are a partner with your provider and your patient and they have your back; they have your best interest in mind. It becomes less of a transaction than it does a relationship-based care.

We just did a study of the VA, which is another very large system that is, in many ways, been in the forefront of transforming health care. They came out with a report that’s called, “The Cover Commission Report.” Actually, NAM is going to do another study with. In that report, they talk about transforming the entire VA model to one that is person-centered, rather than medical-centered; one that is relationship rather than transaction-based, and one that focuses on recovery, not just to the management of the consequences of disease. Then, reframing the financing and the payment model to drive that process.

There’s even descriptions specifically of how to do that. Any providers or teams or health care folks that are listening to this, there are mechanisms for doing that, that are described in that and also, we have them laid out on our website that describes exactly how you can begin to do this, already, in your practice in those areas.

I think the Southcentral model, the VA model, and many others that are around the country that understand these core principles of whole-person care can begin to do this now.

Dr. Moore: There is so much packed into what you’re saying. I wish we had hours to have this conversation. For instance, when you talk about relationship-based care and you talk about recovery versus the typical prescribing and taking care of the prima facie problem, I think all of these things need to be unpacked.

Think about what we’re typically measuring is a process of care. We’re measuring, “Are you, the doctor, adhering to a guideline?” I think about the failings of that. Evidence-based medicine is terrific, but when I’m thinking about a person with two or more conditions, the evidence from one may conflict somewhat with the evidence or care plan for another and now, I have to adjudicate that.

We keep measuring the actions for a disease and missing what matters for the person. I love in the Cover Commission Report, when you talk about care plans that start at that person level and figuring out what’s important to you—what are you trying to achieve and how can we now pivot all of our resources around that. That, to me, is just brilliant.

Dr. Jonas: I think we have tried to build, out of our foundation, a set of easy-to-use and simple tools and resources that allow providers and systems to begin to do this. We call this, “The HOPE Note” toolkit. Everybody knows the SOAP Note, that’s asking, what’s the matter and getting your diagnosis and treatment plan. That’s the center of the primary care model we started with.

The HOPE Note is the Healing Oriented Practices & Environments. That’s starting with what matters to the patient and then, surrounding that with questions that address these underlying drivers of health—the determinants of health, the behavioral and the social. Then, creating a personal health plan that integrates that into their care pathway. There are tools and there are ways to actually do this and these are all free tools on the website that people can download and begin to use right away.

We’re helping systems around the country now implement these approaches as quality improvement approaches to shift to this type of model, regardless of whether you’re primary care or you’re specialty care. This can be done, as I just described, in a specialty situation also, where the person is put in there at the center and a relationship is key. If that’s held onto and that’s understood, that’s the fundamental principle of all good healing. We can bring that and integrate it with the caring system that we have now.

Dr. Moore: Dr. Jonas, before we close, are there last thoughts or advice you would have to health plans, health leaders, states, or employers?

Dr. Jonas: There’s a couple of things I’d suggest. One of those is that before the COVID-19 pandemic arose, there was another epidemic that we were all trying to address in this country. It was called, “The opioid epidemic,” and “The chronic pain epidemic;” right? That hasn’t gone away. In fact, it’s gotten worse, the evidence shows during the pandemic of COVID-19.

It’s going to come back. We need to address it. All the guidelines in the country, from internal medicine to state guidelines to federal guidelines have all said that we need to figure out how to use less opioids and use less drugs for chronic pain management and integrate nonpharmacological approaches. We worked with Tufts University to create a four-unit three CME module called, “Integrative Pain CME.” You can download it free and it’s available. It shows how to begin to do this. I’d encourage everybody to go there and, at least, begin to bring this kind of whole person relationship-based approach to pain management and opioid management.

I would say that the second thing is that, if you’re interested in expanding this into your own practice, contact us. The easiest way is just to email me at my name, drwaynejonas.org, through the website, or wjonas@samueli.org and we can put you on the road to identifying some of these tools.

If there are people that are interested—if there are groups, individual patients, listeners, health systems, providers that are interested in delving into the details of what we mean by this new paradigm, I’d recommend a book I wrote about this a few years ago called, “How Healing Works,” which drew on my 30 years as a military physician, in which I operated in a system where health promotion and healing was truly at the center of what I did. From that, I actually learned how to do it in the hustle and bustle of everyday practice. I urge folks to go there and am happy to provide more information through those systems for those that are interested in being part of this transformation.

Dr. Moore: Dr. Jonas, thank you so much for your time and thoughts.

Dr. Jonas: Thank you, very much, Dr. Moore.

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