What Foundations Can Do to Help Primary Care Succeed

By Dan Lowenstein, Director of Public Affairs, Primary Care Development Corporation

There are enormous expectations that primary care—the health services provided at the principal point of consultation and contact with patients—will be central to lowering costs and improving healthcare quality, and will play a key role in accountable care organizations, care coordination initiatives, and health system restructuring. Despite the opportunities, we don’t yet have the strong primary care system that we need to meet these challenges, and building and sustaining it will require upfront investment in operations, workforce, infrastructure, and communications.

Two issues loom large: (1) Do we have enough primary care, especially in underserved communities? and (2) Do we have the right kind of primary care? In both cases, the answer is no. We have a huge shortage of primary care providers and facilities, which is only expected to worsen as more people become insured and demand healthcare. And most of the primary care providers must adopt a new model of primary care, frequently called a “Patient Centered Medical Home” (PCMH), that incorporates electronic health records, team-based care, proactive care management, and coordination across the provider continuum. Evidence shows that this model leads to better health outcomes, greater patient satisfaction, and lower costs.

Foundations have three important roles to play in the success of primary care:

1. Support struggling providers through transformation
A number of incentives are emerging to encourage health professionals to practice primary care and practice it in a PCMH model. These include loan forgiveness programs for those who practice in underserved communities; higher Medicaid, Medicare, and private insurance rates for primary care; financial incentives for adopting electronic health records and operating as a PCMH; expansion of community health centers; and “shared savings” for those who save money by keeping patients healthy and out of the hospital.

These incentives are important, but they alone are not enough. Adopting new models can be incredibly complex, especially for safety net providers. Some providers are ahead of the curve—those who are already operating as or are close to being medical homes, or who have the capacity and resources to take on major organizational change. But many more are far behind because they run simply to stand still—they are very busy, working day to day, and do not have extra time or resources to dedicate to the process of transforming their practices. They are also unprepared to take the temporary hit to productivity and income that often comes with integrating new technologies or operations.

We can make this process less burdensome for the majority of primary care providers by investing heavily in training and technical assistance to shift practices toward a medical home model of care. This includes training/workforce development that enhances the skills of licensed providers, clinical staff administrators, and other healthcare workers and promotes the use of health technology to drive decision making, quality improvement, information exchange, and care management and coordination. Assistance should focus on methods that build sustained change, including curriculum development for schools that train our providers; on-site and virtual training; and learning collaboratives that bring providers together with experts to share the process of becoming a PCMH and adopting and using health information technology.

2. Provide access to low-cost, flexible capital
The continuing credit crisis, layered on top of pent-up capital need in the primary healthcare market, may severely limit the ability to modernize and equip primary care facilities for the 21st century.

An estimated $10-$16 billion of capital is needed for community health center expansion alone. Community health centers and other primary care providers lack the publicly-supported credit enhancements that are available to other healthcare entities, such as hospitals and nursing homes, as well as to other sectors, such as affordable housing.

Accessing capital and care provider transformation both follow a similar pattern. The strongest and most operationally stable providers will have less of an issue securing credit and investment. The majority of providers, though, will struggle to obtain affordable capital.

Foundations can play an important role in spurring investment in primary care. They can provide critical working capital for a project during the planning process/pre-construction. They can also make grants or program-related investments in projects or capital pools—leveraging private and public sector resources to lower financing costs and improve the terms for primary care providers. Foundations can also support technical assistance that goes along with financing to ensure that projects stay on track and providers have strong, stable, and sustainable operations.

3. Advance communications and help get the word out
Advancing the primary care message is tough. Primary care has to compete for attention and support against players in the healthcare field with many more resources. Primary care also emphasizes “prevention” and does not generate the same excitement as life-saving procedures, groundbreaking research, or a new cancer center. In a media environment that thrives on “disease of the week” stories, medical miracles, and political controversies, telling the primary care story is challenging. But communicating the value of primary care is vitally important to building and maintaining political and financial support.

Foundations should consider supporting national and statewide communications and advocacy campaigns to raise the profile of primary care, its importance in a changing healthcare environment, and the need for more healthcare providers and investment in the sector. In addition, foundations can require that the projects they fund include communications and advocacy components to promote the initiatives and their results.

Five years from now, we don’t want to find ourselves thinking, “Well, we tried primary care, what’s next?” But if we expect too much from an unprepared system, primary care could fail to deliver on its promise. By making upfront investments, assisting those who need it, and communicating value, we can help ensure that we have a robust primary care system ready to take on the challenges in front of us.

Dan Lowenstein was one of the presenters at Philanthropy New York’s February 8th program Strengthening Primary Care: Aligning Healthcare with Our Needs, presented by the Health Policy Working Group, a Philanthropy New York Policy Connects Working Group. He joined the Primary Care Development Corporation in 2008 and oversees PCDC’s public affairs and government relations. He has more than 20 years of experience leading successful health policy, communications, and development initiatives for organizations in the healthcare, nonprofit, and political sectors. Prior to PCDC, Dan was a Senior Advisor at Global Health Strategies and worked with a range of global health organizations, including amfAR, The Gates Foundation, and the World Health Organization. Previously, he held leadership positions with NYS Assembly Health Committee Chair Richard Gottfried, Former NYS State Senator Catherine Abate (now CEO of Community Healthcare Network), and NYU’s Wagner School of Public Service. Dan received an M.B.A. from New York University’s Stern School of Business.

3 Responses to “What Foundations Can Do to Help Primary Care Succeed”

  1. 1 Nur Ibrahim March 13, 2012 at 2:51 pm

    Dan, this a great blog posting and it was really informative hearing from you and Paloma. We are really interested in continuing to explore how funders can support providers though transformations. In fact, we think that principle is applicable in numerous industries. On March 30th, Philanthropy New York will host a webinar on Health Information Technology and we will look at two successful community models: http://bit.ly/wnBTDM

    • 2 Rachael N. Pine March 13, 2012 at 3:33 pm

      Dan, I think one way to tackle the messaging challenges you mention is to talk about the need to strengthen and expand out-of-hospital care, i.e., care that is closer to home and community, more accessible, more culturally competent, often preferred by health care consumers, and, of course, less expensive to deliver. True, this formulation includes types of care other than what is classically defined as “primary,” but primary care is dead center in this agenda and you avoid the association with prevention-only care.

      As an aside, to all interested in the future of primary care, I recently learned about a new and thought-provoking resource. The Kresge Foundation supported the Institute for Alternative Futures in the development of a report entitled “Primary Care 2025: A Scenario Exploration” (2012). The report is available on the Institute’s website.

      • 3 Dan Lowenstein March 15, 2012 at 11:40 am

        Thanks Rachel. You are right. We are indeed talking about community-based interventions with a strong primary care core. Those interventions will be based on the diverse needs of the patients, with some being traditional medical (e.g. dental, ob/gyn, cardiology, etc) and other “nontraditional” interventions (e.g. housing assistance, nutritional counseling, social work). The 2025 report is very interesting and provocative!

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