Want A Healthier California? Invest in Primary Care

A 6-year-old girl rushes into an emergency room (ER) on a gurney, her chest violently heaving as her lungs beg for oxygen. Her uncontrollable wheezing indicates something more severe as she is placed in a treatment room. The breathing is loud enough that the medical team can hear the deep crackles of an inflamed airway. A mask hissing with evaporated mist is placed over her mouth. Only then do her lungs stop gasping.

This was not the work of a novel coronavirus.

This was asthma.

This was one of many harrowing images I saw as a frontline medical scribe in California’s emergency rooms. This is not something I want to continue seeing long after my own medical training as a clinician.

Problem Statement:

Asthma is a chronic respiratory disease causing inflammation of the airways, the lung’s primary mechanism of breathing. If it is not treated properly, it can lead to hospitalization and even death. In the United States, it affects 1 in every 13 people, with 8.4% of them being children. Approximately 1.5 million children in California have been diagnosed, making exercise, school, and simply breathing all the more difficult.

I don’t imagine a world where families are suffering through agonizing waits in the ERs just to receive a license to breathe. Our bureaucratic protocols do not need to introduce higher costs of care that affect both children and the system, itself.

So, how can we do better? How can we reduce ER visits and improve the quality of life for children diagnosed with asthma?

The situation is not one-dimensional; it requires an understanding of the multiple factors that led us to the current state of chronic disease burden in California.

Problem Factors:

As California has augmented insurance and health system reforms under the Affordable Care Act (ACA), the shortage of primary care clinicians, coupled with the aging healthcare workforce, presents an uncertain future for the effective delivery of primary care services. A litany of research has exposed the dwindling growth in the supply of primary care professionals in the state.

1. Shortage of primary care professionals

Recent statistics signal macabre projections with an estimated shortfall of 10,500 primary care clinicians by 2030, with 4,100 additional primary care physicians needed to close the health gap. Even amongst the mid-level providers, there is a scattered distribution in the supply of primary care services: 22% of physician associates (PA) and 50% of nurse practitioners (NP) provide primary care, in contrast to 36% of active full-time equivalent physicians. To make matters worse, the latest report by Coffman et al. shows the current supply of primary care physicians barely meets the minimum per capita ratio recommended by the Council of Graduate Medical Education.

2. Structural Determinants of Health

Another paramount concern is access and a population’s social vulnerability. Research by Nayak et. al found regions with high social vulnerability, explained by poor social support resources (i.e., housing, employment, disability), were more susceptible to asthma flare-ups and an increased chance of visiting the ER. These same regions were afflicted by low coverage of primary care providers. Additionally, in 2012, Largent et.al demonstrated that access to quality healthcare is a significant barrier to adequate asthma treatment and has had significant impacts on the rates of emergency department (ED) visits, most prevalent in children’s age group of 0-4 years.

In 2019, data from Let’s Get Healthy California reveals that Fresno County, a region in the San Joaquin Valley (notoriously low rates of licensed primary care physicians) unfortunately boasts an asthma ED visit rate nearly double the state average (125.9 vs 63.4 visits per 10,000 residents, respectively). This effect is compounded by other factors, such as household income and health insurance, which downstream affect access to outpatient care.

3. Concern for Primary Care Overall

The concern for the state’s healthcare workforce persists as the apparent shortage of primary care professionals is likely contributing to the rate of chronic illnesses. While asthma is addressed as a great concern, this is not at the exclusion of other pressing and equally harmful diseases like diabetes and hypertension. As Dr. Coffman clearly states: “If we continue along our current path, more and more Californians will need to visit the emergency room for conditions like asthma, ear infections or flu because they lack a primary care provider.” If California continues to operate on these margins, we are significantly compromising the state’s healthcare system and its population, leading to a waste of resources and unnecessary complications/deaths.

For California, the state must begin to develop programs and policies that address the great shortage of primary care clinicians to effectively support its children and the generation of adults and beyond.

Policy Alternatives:

The asthma crisis is not an isolated phenomenon. It is a result of disinvestment in primary care, and profit-driven focus on patients, that has influenced the reduced access to high-quality preventative health in California. Addressing primary care investment in this state has increasingly shown a pronounced effect on population health and equitable health outcomes. To realize the benefits of this, it requires investing in primary care by developing payment systems, building clinical workforce capacity, and addressing underlying social factors.

Recommendation 1: Investing in Primary Care Training

1. Increasing funding to primary care residency programs. This mechanism will support more space for burgeoning health professionals to train in providing equitable access to care. This is in part due to California’s Song Brown Healthcare Workforce Training Act, which aims to ensure access to primary care services by bolstering the training of such healthcare providers. For example, recently, the California Office of Statewide Health Planning and Development (OSHPD) awarded $875,000 to UC Davis Health residency training programs. This funding supports specific programs, such as creating more pediatric health training or funding faculty mentors for behavioral health skills development.
2. Develop residency programs within under-resourced regions of California. Areas like Inland Empire, LA County, or the San Joaquin Valley have disproportionately higher rates of chronic diseases, like asthma, and require place-based programs that meet their clinical needs. Programs like UC Davis’s PRIME position students within underserved areas and train them to enter primary care practice in an accelerated timeline to improve the availability of services in these areas and increase workforce numbers. By supporting such programs, it can amplify the efforts to have meaningful access to primary care.

Recommendation 2: Implementing Value-Based Payment Models

Access to primary care, among other factors, depends upon the support primary care providers receive. In other words, a sustainable business model is needed to retain a new generation of providers and allow it to be a viable career option.

1. Increase the share of healthcare costs towards primary care. In recent years, states, such as Colorado and Oregon, have experimented with systems tailoring payment to primary care clinicians and goals on population health management, instead of outpatient or specialty care. Paying primary care providers (and coordinated care organizations) for reaching specific primary care targets instead of a per-service model (i.e., after performing a procedure) ensures specific primary care attributes are reached. Through such a model, payment is risk-adjusted to reflect the health status of the served population; this cost shifting reduces unnecessary use of hospital/emergency services, and any saved expenses are categorized as investments into these physician groups.
2. Measure and track data. Public and private healthcare organizations/payers should share the goal of public reporting the share of expenditures towards primary care. This can be used to standardize payment caps and find ways to reduce unnecessary waste through the feedback of improvement specialists, funders, policymakers, and advocacy organizations. In addition, progress can be measured to track if there are increases/decreases in primary care spending to identify the impact, or lack thereof, of specific changes in funding. This public data can be used to create a report card assessing gaps in healthcare value amongst primary care services across the state.

Recommendation 3: Adopting a Socialized Medicine Model

1. Organize a community-oriented primary care model. Often, community organizations within local regions/municipalities have a deeper understanding of the community's needs and can assume responsibility for supporting healthcare teams in identifying them. This approach can be used to not only treat diseases (i.e., asthma) but also develop coordinated programs for health prevention, healthy lifestyle, and social support. Organizations like the Jakara Movement (California’s largest Sikh-Punjabi CBO) leverage the broad impact it has across their community in the Central Valley through years of strategic partnerships and relationships with community leaders to advance new health models. For example, Jakara has increased health access and support measures of health outcomes for families and individuals through door-to-door interactions, phone follow-ups, and town-hall events that create an enduring relationship with the local community. In addition, they have developed health literacy workshops, organized health resource fairs, and supported community member case management for issues related to Medi-Cal, CalFresh, and CalWORKs.
2. Exchange data with CBOs through partnerships. Gathering data from community organizations that have formed extensive relationships with specific patient populations can help define important social metrics. Organizations can share these social determinants data and information to integrate within health care services, such as healthcare screenings or validating current medical assessment tools.

Episodes of severe asthma exacerbations are just the tip of the iceberg when it comes to California’s inadequate investment in the primary care workforce. Concerted efforts in developing stronger residency programs, adopting value-based payment models, and integrating socialized mechanisms of community support are innovative ways to tackle an issue that will define the generation of Californians in the coming century.