In 1978, when I was a toddler in Queens, NY, the world came together to define the future of primary health care. The culmination of the International Conference on Primary Health Care was the landmark Declaration of Alma-Ata, which set forth a vision of primary care as not merely a service for individual patients but an engine of equitable health for all.
Many countries in the world embraced that vision, designing primary care practices to understand the needs of the households within about a 50-square-block radius and serve as a central hub to coordinate care of that population (for a vivid description, see Atul Gawande’s story about Costa Rica in a recent New Yorker). The U.S., however, mostly went the other way, creating a healthcare system that continues to reward downstream, often preventable, and sometimes wasteful care, at the expense of upstream health equity interventions.
It’s time to change direction.
As we witness resurgent calls for health equity, we should remember that primary care, implemented right, is an equity strategy. But only if it’s designed in the right way, with aligned incentives and adequate support.
Fortunately, we don’t have to invent this anew. There are effective models that already exist. The shift entails transforming primary care at three levels:
- Transform our primary care practices so that they can assess and help address the social and structural inequities that impact our patients, their families, and their neighborhoods.
- Transform our systems to not only support equity-oriented primary care but also to change the way we pay for it, so that community-centered equity is a core function, not only an afterthought.
- Transform our society by realigning the policies that reflect what we value and what we don’t. That includes reupping investments in primary care and centering health equity in value-based payment and delivery reform. It also means aligning these reforms and investments by place—as Alma-Ata envisioned—and shifting our paradigm of primary care from a consumer service to a community service.
At HealthBegins, we’re developing resources to help primary care practices and health systems find their path to these changes. For example, we’re working with the California Improvement Network to curate a practical toolkit to help primary care practices advance racial equity, to be released early next year. We’re producing resources like the AMA Steps Forward module, to provide concrete examples of how to drive equity-oriented primary care transformation, with a focus on racial equity. And we’re helping primary care practices, like those in the national School-Based Health Alliance, understand how the new 2021 Evaluation & Management (E&M) coding guidelines can be used to identify social risk in patients’ lives and advance equity.
We’ll keep sharing more resources and opportunities to accelerate primary care transformation and health equity through place-based payment models, as we discover them. If you’re aware of or involved in this type of work, please feel free to contact us. We’d love to connect.
Primary care, where I have spent most of my practicing years as a physician, is close to my heart. It always deserves more credit, attention, and funding than it gets—and this moment of equity awareness opens a door for us to give it that. But this moment is not just about making existing primary care better. As Alma-Ata reminds us, it’s about reimagining primary care as an indispensable strategy for advancing equity and the right to health for all.
Rishi Manchanda, MD, MPH.
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