Until 2021, most Texans didn’t think twice about the state’s electrical grid, believing a large, energy producing state could meet Texans’ power needs — rain or shine. But that year, the grid widely failed when an Arctic snowstorm strained its capacity, leaving millions without electricity or heat for several days and wreaking havoc on the state. The collective shock of that experience drew Texans’ attention to the fact that the electrical grid does not mind itself. Rather, it needs regular maintenance, investment, and research and development to ensure it can keep pace with the state’s growing population and changing energy needs.
Like the electrical grid, Texas’ primary care system is unable to keep pace with the needs of a modern state. According to a report by the Commonwealth Fund, Texas ranks dead last among the states in access to health care and is among the most expensive places to receive it if you don’t have coverage. Over the past year, state and national headlines, such as “The Doctor Won’t See You Now,” have revealed how challenging it can be to obtain a primary care appointment, even if a patient already has an existing primary care physician, much less if they don’t. Of the state’s 254 counties, 224 are designated as primary care health professional shortage areas. In a state brimming with world class medical schools, health science centers, and hospitals, many Texans have been left scratching their heads, asking how the state’s primary care system got to this point.
Myriad, cumulative, festering factors led Texas to this moment, most worsened by the lingering effects of the COVID-19 pandemic. Among the challenges: the so-called “reimbursement treadmill,” where clinicians try to squeeze more patient visits into each day to offset declining insurer payments and higher overhead costs; unrelenting and unproductive paperwork hassles, which reduce time with patients; inoperable electronic health records; shortages of every type of personnel, from physicians to nurses to front office staff; and the need to design and implement better payment models without creating new, costly burdens.
Despite these challenges, a robust primary care “grid” is vital to Texas’ interests, serving as the bedrock of the state’s health care system. Nationally, primary care practices provide more than one in three health care visits and often serve as the only source of care for patients, including patients with chronic conditions, such as diabetes, or mental health needs. Indeed, for underserved communities, primary care often is the only option.
Numerous studies show that robust access to primary care benefits both individual patients and communities. Patients with a regular primary care relationship have better health outcomes, higher satisfaction, and lower overall health care costs, while communities with higher numbers of primary practices enjoy better and more equitable population health, making primary care a common good — like electricity.
Texas should establish and fund its own Primary Care Research and Innovation Lab, housed within one of the state’s health science centers, with the express purpose of evaluating strategies to improve primary care resiliency, capacity, access, efficacy, cost effectiveness, and interprofessional, primary care collaboration.
How do we solve this lack of access to care? Increasing the primary care workforce is the first step — a step Texas has taken and must continue. Over the past several legislative sessions, lawmakers have allocated significant funds to expand graduate medical education, grow rural primary care training programs, increase access to primary care loan repayment, incubate new federally qualified health centers, and more.
However, expanding the primary care workforce without better understanding how to improve the practice of primary care, its integration into the larger health care system, and its ability to adapt to a rapidly growing population is like installing more power lines without knowing if they’re going into the right place or can handle the load. Texas should now pair investments in its primary care workforce with research into how to improve its efficacy and ingenuity, developing strategies to improve patient management, health outcomes, and interprofessional collaboration. In other words, Texas must help primary care practices adapt now so they will be available in the future.
Research dollars dedicated to primary care account for only 0.3% of all federal research funding. Texas similarly spends little to no dollars specifically on primary care practice improvement. As a result, primary care clinicians are reliant upon research conducted in settings unlike theirs or among patient populations that do not directly correspond to primary care.
According to the National Academy of Science, Engineering and Medicine, “The neglect of basic primary care research … not only adversely affects primary care outcomes but also leads to the lack of a population-based understanding of illness and disease along the health care spectrum. Better [primary care research] support could lead to answers to questions that are critically important for improving population health.”
For example, patients seen in primary care settings often present with a constellation of vague symptoms, not lending themselves to an obvious diagnosis. This means primary care physicians must acquire different expertise and skills to adeptly develop a differential diagnosis. Additionally, research is needed to:
- identify the problems that arise in daily practice that create the gap between recommended care and actual care;
- demonstrate whether treatments with proven efficacy are truly effective and sustainable when provided in the real-world setting of ambulatory care; and
- provide the “laboratory” for testing system improvements in primary care to maximize the number of patients who benefit from medical discovery.
Without investing in primary care research, it’s nigh impossible to develop new primary care systems, delivery models and primary-care based clinicals interventions necessary to modernize and adapt practice to the 21st-century. In 1996, the Institute of Medicine, now NASEM, recommended that the National Institute of Health increase funding for research on primary care. Yet, in nearly two decades, the needle has barely budged.
Moreover, Texas, like the nation, spends only about 5% of health care dollars on primary care services. If dollars talk, then what the state spends on primary care services speaks volumes, contributing to fewer medical students choosing the specialty as well as experienced clinicians deciding to pursue other specialty practices or to retire.
Keys to success: Promoting innovation, sustainability and capacity
Instead of waiting for federal agencies to lead, Texas should do so, establishing and funding its own Primary Care Research and Innovation Lab, housed within one of the state’s health science centers, with the express purpose of evaluating strategies to improve primary care resiliency, capacity, access, efficacy, cost effectiveness, and interprofessional, primary care collaboration.
The lab would provide grant dollars to medical schools and health systems, with at least 50% of dollars dedicated to research within community-based settings, including private physician practices. Potential functions include the following.
- Track statewide and regional primary care capacity and develop data-driven strategies to improve workforce and infrastructure needs.
- Assess how today’s Texans view and understand primary care, with the goal of increasing primary care usage to improve Texans’ health and constrain health care cost growth.
- Identify cost-effective initiatives to expand existing primary care capacity, harnessing technology, delivery system redesign, health information exchange, new developments in artificial intelligence, virtual care, and expanded use of community-based, non-clinical or semi-clinical professionals, such as medical assistants, community health workers, or primary care “techs.”
- Assess opportunities to improve interprofessional collaboration across primary care clinicians as well as specialty care clinicians to reduce duplication, fragmentation, and costs.
- Educate patients and payers about primary care’s foundational role in achieving better health outcomes and cost effectiveness.
- Develop educational and policy proposals to advance team-based care as well as provide technical assistance and training to accelerate its adoption.
- Evaluate use of primary care collaboratives or extensions, similarly to those used in agriculture, to accelerate adoption of primary care best practices.
- Assess whether and how primary care clinical training should change to meet Texas’ growing population and geographical differences.
- Develop strategies to help primary care clinicians better manage patients with multiple conditions despite competing evidence-based guidelines.
As the state’s primary care system goes, so goes the rest of the health care system. Texas has long incubated state-of-the-art medical and specialty services, such as cancer research to improve cancer treatment, with the goal of improving the health of its own residents as well as the nation. That expertise now should be harnessed to research and reimagine a sustainable, resilient, integrated, cost-effective, and accessible primary care model that can power Texas’ health care system.