Primary Care Needs to Move to Forefront of U.S. Health Care

In an article in Harvard Business Review, Elation Health CEO Kyna Fong challenges the U.S. health care system’s lack of focus on primary care. She discusses what makes primary care different from subspecialty care, and the mistake of using the same evaluative methods for both.

Fong cites a 2021 report from the National Academies of Sciences, Engineering, and Medicine. The report concludes that primary care is the only medical specialty tied to increased longevity, better health equity, and population health improvements.

Yet the U.S. system is designed to stymie the exact qualities of primary care that allow it to lead to better patient outcomes and make health care more cost-effective. 

A Faulty System

Focused too heavily on the processes and metrics used to evaluate subspecialty care, the current system disregards the true value of primary care medicine. Family medicine, internal medicine, and pediatrics form the backbone of quality health care.

Primary care is patient-focused and collaborative. The relationship between physician and patient, and the trust required to maintain that relationship, are the cornerstones of the positive outcomes highlighted in the NASEM report. 

Where streamlining may work elsewhere in the healthcare industry, primary care is unique. An insurance company checklist of diagnostic questions fails to allow for the open-ended conversations that lead to individually based clinical decisions.

Primary care decision-making is complex and individualized. Attempts at standardization ignore that complexity and poorly serve patient needs.  

In the U.S., which spends less on primary care than other developed nations, reliance on forced metrics leads to overworked, burned-out primary care doctors. They are burdened with documentation requirements that don’t reflect the reality of their practices.

Primary Care and Sleep Medicine

How can primary care doctors help diagnose sleep issues with their patients? They are in the unique position of understanding underlying factors that may lead to insomnia and other common sleep disorders.

The primary care doctor’s relationship with the patient gives them insight into life changes, health issues, and other factors that may contribute to sleep issues. This level of individual understanding allows them to determine when sleep problems require specialty care.

How Can Primary Care Doctors Refer Patients to Sleep Specialists or Neurologists?

Primary care doctors, nurses, and nurse practitioners work with patients to determine if sleep problems can be addressed by lifestyle changes. If those changes don’t work or the physician suspects a serious underlying sleep disorder, they refer patients to appropriate sleep medicine professionals.

Taking the first steps with their primary care doctor allows patients to receive appropriate referrals to the right specialists. 

Fixing the System  

Fong identified three major areas of change that would enable the U.S. to reap the benefits of primary care.

Payment Methods and Models

Primary care physicians make less money than their subspecialist colleagues. They are also forced, by the government and insurance companies, to justify their fees using documentation methods that fit poorly with primary care’s focus on the individual.

Reporting requirements that do not reflect the complexity of primary care practice diminish its importance. Payment methods and models need to be focused on outcomes and public good rather than standardized metrics.

Fong asserts that it is possible, and necessary, to tie incentives to improved long-term outcomes and the high-value, whole-person centered care provided by primary care physicians.

Electronic Health Records

Electronic health records (EHR) in their current form do not align with the way primary care medicine works. These systems were built to optimize medical billing, not patient care.

Current EHRs don’t adequately support the complexity of patient-focused care. They need to be redesigned with a focus on collaborative care and patient-relationship-based medicine.

Removing the fee-for-service model being imposed on primary care by EHRs allows providers to ask open-ended questions and have conversations that result in patient-based clinical decision making and better, less costly patient outcomes.

Medical Education

Primary care is de-emphasized in American medical education. Most students complete their training in large hospitals with little exposure to primary care. 

Students are also exposed to the bias built into billing-focused hospital EHR systems. Glamorized, high-paying subspecialties are the emphasis of most students’ education. Primary care is portrayed as a lesser option, with poor conditions and low pay. Many students who might otherwise choose primary care are steered away before they ever try it.

Fong notes that a focus on primary care is well-recognized as a way to improve the U.S. health care system. Despite that recognition, payers and systems are still forcing primary care into boxes that simply do not fit.

She promotes reinventing the way we measure success in primary care. She suggests starting by acknowledging the unique benefits of primary care, from reduced cost to improved patient outcomes and satisfaction. Then, she contends, we rebuild the system around the fundamental notion that primary care is a public good.


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