There are powerful reasons to move to a value-based primary care system. Highly effective primary care is an indispensable piece of that effort. It is critically important that we move rapidly from Primary Care 1.0 and 2.0 to Primary Care 3. The latter provides a molecular medical management framework as opposed to the traditional organ system management. We believe that implementing this type of approach will unlock the full potential of primary care.
Why is primary care so important?
Research demonstrates that a focus on primary care has many benefits. These include:
- better health
- lower costs
- lower mortality
- higher patient satisfaction
- fewer ER visits
- reduced hospitalizations
Primary care provider reimbursement generates just 7.7% of healthcare costs but PCPs direct most spending through their referrals. There is evidence that this is exacerbated when PCPs are employed by hospital systems.
It is important to recognize that the costs of care are not distributed evenly:
- Ninety percent of the nation’s healthcare expenditures are for people with one or more chronic conditions. Further, forty-one percent of costs are tied to just 12% of the population that has 5 or more of them.
- Just 5% of patients generate over half the costs. This is, in part, because they don’t receive effective primary care upstream to reduce serious comorbidities downstream.
An interesting twist is that primary care has already begun to segment. For example, urgent care providers and hospitalists are organized to meet the specific needs of people with acute or intensive needs. In addition, some primary care providers are specializing in delivering care almost exclusively via telemedicine. Primary care teams that focus on chronic conditions are critical to improve overall health and save money.
Stages of Primary Care for cardiometabolic disease
Let’s look at the different stages of Primary Care using the management of cardiometabolic disease as an example.
(c) Bill Bestermann MD
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Primary Care 1.0
In primary care 1.0, physicians practice what is called “usual care.” They manage chronic conditions, such as the prevention and management of chronic kidney disease (CKD), using any medication that has been approved for the purpose. They may not specifically take into account the molecular medicine and the root causes of the condition.
Many of these patients are diabetic and hypertensive. Aggressive treatment of these conditions is needed to prevent the development and progression of kidney disease to end-stage renal disease requiring dialysis.
Related Content: A PCP Imperative: Integration of Behavioral and Physical Health Care
In addition, socioeconomic factors also play an important role. The cost of care can be a huge barrier to effective primary care access not only for the uninsured but also for the under-insured and those with high cost-sharing plans.
For people who can gain access to current primary care, treating hypertension and diabetes in usual care can be effective in preventing progression to dialysis. However, depending on which drugs are chosen to manage them, costs of care can vary widely.
Consequences of failure to prevent progression of CKD
Failure to prevent the progression of CKD poses significant health risks for patients. For example, one study found that “cardiac and vascular mortality are several times higher in dialysis patients than in the general population.”
Further, progression to dialysis is very expensive. The diabetic patient without CKD costs $10,721 annually. With stage 3 CKD and any progression, the cost is $31,693. The dialysis patient costs $62,091 a year.
Once a patient goes on dialysis, they automatically go on Medicare.
Even if you are miserly and hard-hearted…even if you care nothing for the plight of people less fortunate than you… you are going to pay for their much more expensive care down-stream.
It is in everyone’s hard financial interest to see that every American has access to cost-effective primary care, including critical generic medications.
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Primary Care 2.0
As effective as Primary Care 1.0 is, it does not begin to realize the benefits that we could deliver with currently available best practice paradigms for chronic condition management. This is what takes place in Primary Care 2.0.
Using the prevention of CKD as an example again, we see that physicians aggressively and cost-effectively manage diabetes and hypertension using drugs that go beyond traditional risk factors.
They also follow guidelines that advocate focused, multifactorial interventions based on scientific evidence. And, they take cost into account by using generic drugs that target root causes. They also set aggressive clinical targets following their patients closely so they can tweak the interventions as needed.
The Steno-2 Trial
The Steno-2 trial is a great example of such an intervention. Participating physicians followed a protocol that combines ACE inhibitors for hypertension, statins for cholesterol, metformin for diabetes, and aspirin to prevent clots.
When applied, this approach has produced impressive results:
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- six-fold reduction in dialysis compared with usual care
- four-fold reduction in heart attacks
- five-fold reduction in strokes
- eleven-fold reduction in coronary stents
- three-fold reduction in amputations
- three-fold reduction in dialysis
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Optimal medical therapy
Luckily, optimal medical therapy can be systematized, industrialized, and scaled. There is no reason why patients cannot reliably receive this type of treatment regardless of whether they live in a big city or a small town.
Similar approaches could also (Note: this article is behind a paywall) be used to reduce the incidence of Alzheimer’s disease and other expensive chronic conditions in addition to dialysis. We believe that Primary Care 2.0 is a much more effective way to manage cardiometabolic diseases.
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Primary Care 3.0
It is only with Primary Care 3.0 that we begin to see its full potential. There are thousands of people developing the new science of molecular medical management. However, few are working on translating the new science from bench to bedside.
This is unfortunate because this new approach can move us beyond a system arranged around traditional risk factors and organ systems. It can move us to a much more precise approach targeting the molecular biology that forms the basis of chronic diseases and accelerated aging.
Understanding the full potential of primary care redesign requires a very short trip into the basic science weeds. If you just understand the rest of this article and the links, you will understand what next-generation chronic disease management could be. It is not that hard.
For example, elevated LDL cholesterol levels are a traditional target for therapies to reduce the risk of cardiovascular events, such as heart attacks and stroke. However, about half of all heart attacks occur in people with normal levels of LDL cholesterol. This suggests that other factors may be contributing to the risk in those people. Several seminal studies have pointed at inflammation as a critical pathway in the pathogenesis of atherosclerosis.
The Jupiter Trial
Paul Ridker is a cardiologist at Harvard Medical School. He is the leading proponent of the “inflammatory hypothesis” of cardiovascular disease. The 2008 Jupiter trial made him famous in medical circles.
The trial enrolled 17,802 healthy patients with normal LDL cholesterol levels (according to guidelines at the time) but a high level of the inflammatory marker C-reactive protein (CRP). Half of the patients were randomly assigned to receive the statin and half did not.
Although many in the public think of statins as cholesterol-lowering drugs, they also have significant effects in reducing inflammation. The results were dramatic leading the cessation of the trial after a median of ~2 years. Rosuvastatin treatment cut the incidence of a first cardiovascular event in these individuals by half. LDL levels were reduced by 50% and CRP by 37%.
The CANTOS trial
Dr. Ridker expanded this concept in the 2017 CANTOS trial designed to determine the impact on cardiovascular events if inflammation was reduced but cholesterol levels were not impacted.
Patients with a history of heart attack and a high CRP received the injectable monoclonal antibody canakinumab that neutralizes the inflammatory mediator interleukin 1B (initiates inflammatory signaling cascade). That intervention reduced heart attacks by 15%.
This study provided compelling evidence that targeting inflammation instead or (or in addition to) lowering lipids is a viable approach to the prevention of cardiovascular disease.
In a follow-up review, Ridker and his colleague, Aaron Aday, wrote the following:
“Successfully addressing traditional CVD risk factors should not falsely reassure clinicians and patients that nothing more can be done to further reduce [CVD] risk…”
Systems biology
Dr. Ridker summarizes the implications like this: “CANTOS is what we call systems biology.
When I was a medical student, we taught heart, lung, kidney, brain. however, We don’t do that anymore. Instead, We teach inflammation, fibrosis, and metabolism.
The best scientists at Harvard are calling for a move away from a medical system designed around organ systems. Instead, they advocate moving toward a system based on genetics, epigenetics, and molecular biology. This is because the same molecular signaling that causes a heart attack also causes stroke and kidney failure.
It makes no sense to send these people to cardiologists, neurologists, and nephrologists. The best management will not come from partialists. It will come from generalists who are experts in molecular medical management. That, in a nutshell, is primary care 3.0.
Other articles in this series:
Healthy Life Extended by Eight Years in a Landmark Study
Heart Attacks: When Will We Finally Do What Needs to Be Done
Is There Really a Way to Reverse Diabetes?
A Unifying Hypothesis of Chronic Disease and Aging
Erectile Dysfunction: Is It a Sign of Heart Disease?
Reshaping Healthcare: What We Can Learn From Alaska
William H. Bestermann MD and Patricia Salber MD, MBA
William H. Bestermann Jr., MD is a board-certified internist who has practiced preventive cardiology for more than 20 years. His core expertise is consistently producing optimal medical therapy (OMT) for cardiovascular and related conditions. He does this by using evidence-based care processes consistent with best practices.
He looks at OMT as a product. He understands how health care organizations can combine new systems, new science, and new payment models to produce that product much more consistently. That combination can be standardized, scaled, and industrialized. These new systems combine teams, protocols, population health tools, clinical/financial analytics, and provider training. Certain clinical interventions reduce clinical events more than they impact the target risk factor.
Dr. Bestermann has developed integrated protocols that combine those interventions which maximize impact on weight reduction, minimize drug interactions, and reduce side effects. When these systematic interventions are combined, they dramatically reduce the cost of care, prolong life, and delay cardiovascular events.
Dr. Bestermann wrote the first article on a systematic, integrated approach to the metabolic syndrome. He collaborated later with multiple academics and community leaders in a more detailed article on metabolic syndrome science and treatment. He proposed a new mechanism of action for metformin explaining its impact on cardiovascular, events, cancer, and aging.
He supervised an advanced medical home team within Holston Medical Group for cardiometabolic conditions that contained an ambulatory care residency for PharmDs. The team managed high-risk diabetic and hypertensive employees of Eastman Chemical Company.
He is also a senior clinical advisor for the Quality Blue Primary Care initiative at BCBS of Louisiana. That effort reduced hospital admissions, length of stay, and specialty referrals while lowering per member per month costs. He has personal experience producing OMT in multiple medical settings.
He has become convinced that only evidence, data, and transparency can deliver us from the low-value healthcare that prevails across the United States. There are many vendors making claims regarding their clinical and financial success. Most of those claims are not valid. Almost no one is consistently applying optimal medical therapy to patients with cardiovascular and related conditions in a way that prolongs life, delays cardiovascular events, and reduces costs. Dr. Bestermann submitted his approach to the Validation Institute and received their stamp of approval.
Patricia Salber, MD, MBA is the Founder and Editor-in-Chief of The Doctor Weighs In. Founded in 2005 as a single-author blog, it has evolved into a multiauthored, multi-media health news site with a global audience. She has been honored by LinkedIn as one of ten Top Voices in Healthcare in both 2017 and 2018.
Dr. Salber attended the University of California San Francisco for medical school, internal medicine residency, and endocrine fellowship. She also completed a Pew Fellowship in Health Policy at the affiliated Institute for Health Policy Studies. She earned an MBA with a health focus at the University of California Irvine.
She joined Kaiser Permanente (KP)where she practiced emergency medicine as a board-certified internist and emergency physician before moving into administration. She served as the first Physician Director for National Accounts at the Permanente Federation. She also served as the lead on a dedicated Kaiser Permanente-General Motors team to help GM with its managed care strategy. After leaving KP, she worked as a physician executive including serving as EVP and Chief Medical Officer at Universal American.
She has served as a consultant or advisor to a wide variety of organizations including digital start-ups such as CliniOps, My Safety Nest, Doctor Base. She currently consults with Duty First Consulting as well as Faegre, Drinker, Biddle, and Reath, LLP.
Pat serves on the Board of Trustees of MedShare, a global humanitarian organization. She is also Chair of MedShare's Western Regional Council.
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This is for Dr. Drummond: Thank you for pointing out the imprecise way that I pointed to the medical system ignoring “this wonderful new science.” I think we agree. The failure is at the leadership level. There should be a system to translate the new science and systems to benefit primary care. Primary care providers themselves are doing the best they can to provide excellent care for their patients under very difficult circumstances. They don’t have time to do much more than address the tyranny of the urgent.
Whenever I see things that don’t make sense or decisions that fly in the face of logic … I never assume it is a product of conscious intention. This is not a question of anyone “ignoring this new science” … that would mean they were aware of it, understood it and consciously chose to NOT USE IT. And that is clearly not what is happening.
The doctors and other front line caregivers are overwhelmed (50% average burnout rate) with delivering the current state of care using their current training and experience. They are too busy putting out today’s fires to learn, understand and deploy the 3.0 innovations.
This is an example of “opportunity cost” rather than deliberately throwing a spanner in the gears of a new system of care desperately trying to birth itself.
Where does the leadership come … to turn the ship to a new normal? I am not sure and there are a number of candidates.
Clinicians could lead with studies of cost effective better outcomes
The payors could lead by not tolerating the current state of affairs and mandating newer and more cost effective measures
Government could lead by playing that same payor role with Medicare and Medicaid.
Great article. Great vision of the future healthcare system. Now who do you have to collaborate with to get a pilot going somewhere.
My two cents,
Dike
Dike Drummond MD
CEO http://www.TheHappyMD.com
Thank you so much Anne for your insight. This is my first post in a while and improvement certainly will require more than new science and primary care reorganization. In fact, most improvement efforts fail because they do not embrace a comprehensive solution:new science, new systems, and new payment models. Success will require all of these elements and bringing the stakeholders together. There is a lot of heavy lifting to be done and all members of the team have a critical role. Advanced practice nurses do a great job with managing chronic diseases and I am a great fan. I am delighted to see you working to make healthcare better, and I hope we can find ways to help each other
Interesting article. I would have liked to see how Primary Care 3.0 is using a team approach to educate and empower the patient and their family to understand thier disease and the importance of adherence to the plan of care.
The article focuses on science which is important but misses the point of helping the patient be engaged in their care. If the patients don’t take the medications or comply with the plan of care, we are still at square one.
Having a nurse case manager/patient advocate on the team to identify barriers is key to educating and empowering the patient/family to understand their role. Primary Care models that have a team to work with the doctor is as important as the science of diagnosis and treatment.
Thanks, Anne. We’re 100% in synch with you on patient engagement. The author of this article, however, wanted to make the point that we are missing the boat if we keep managing chronic disease in different organ system silos instead of moving to a more comprehensive approach that he calls molecular medical management. We would, of course, welcome an article from you about adding nurse case managers/patient advocates to the team.