Primary Care, Not Palaces

Real estate in Manhattan is a blood sport. Here you can not only sell the land beneath your feet but the air over your head. Closets are either luxuries or potential sources of revenue. And on this island no real estate is more prized than one with a river view. On the high floors, businesses, residents, and hotel guests can turn their backs on the city and escape the teeming masses below. They can gaze out across the glinting water and at smaller buildings to the horizon.

Cruise down the East River—perhaps on a New York City ferry—and you may be struck by something curious. The newest, largest, and most expensive compounds along the water belong to the medical-industrial complex. The Hospital for Special Surgery, Memorial Sloan Kettering, NewYork-Presbyterian/Weill Cornell Medical Center, and NYU Langone line up like gleaming flat screen TVs on display, each competing for your attention and dollars. On the other side of the island, NewYork-Presbyterian/Columbia University commands the heights above the Hudson.

The phenomenon is hardly unique to New York. In places with more land, growth has spread out, not up. Medical offices sprout around shiny hospital buildings, surrounded by a sea of parking lots. All over the US, the houses of the healing arts have become temples to commerce. Hospital administrators have become business developers and real estate moguls.

This is not to disparage the critical medical care provided by the dedicated clinical teams in these institutions. Nor is it to deny the powerful role health care plays in economic development and scientific discovery. But if one of the primary goals of public policy is to help individuals live long and fulfilling lives in healthy and safe communities, the consolidation and specialization of health care should not be a priority. Primary care should be.

After all, inadequate health care only contributes to 10% to 20% of premature deaths in the country. And among health care services, adequate primary care is far and away the most effective at promoting long lives. A study by Sanjay Basu, MD, PhD, and colleagues published earlier this year showed that an increase of 10 primary care physicians per 100,000 people resulted in an increase in life expectancy almost three times higher than a similar increase in specialty physicians.

Yet our public policy continues to promote health care specialization and aggregation, and the medical-industrial complex is just playing by (and defending) the rules of the game. A new Milbank Memorial Fund–supported study from the Patient-Centered Primary Care Collaborative and the Robert Graham Center estimates 5.6% of health care expenses in the US goes to primary care. This is dwarfed by shares absorbed by hospitals, other physicians, and pharmaceuticals—and by the roughly 14% of total health care spending OECD countries devote to primary care.

Source: PCPCC. Investing in Primary Care: A State Level Analysis. 2019.

Significantly, states that spend more on primary care get better results. Increased primary care spending, the Graham Center researchers found, was associated with lower rates of hospitalization and ED use.

Source: PCPCC. Investing in Primary Care: A State Level Analysis. 2019.

The study found a twofold variation in primary care spend between the highest and lowest states, with Minnesota topping out at a still-paltry 7.6 percent. The “Land of 10,000 Lakes” did not end up with a relatively high primary care spend figure by accident. Claire Neeley, MD, CEO and president of the Institute for Clinical Systems Improvement in the Twin Cities, explains the investment was the result of a demanding and engaged employer purchaser community; a culture of public performance measurement of health providers, coupled with improvement collaboratives; and local medical schools’ commitment to valuing and promoting primary care.

The health care “edifice complex” has largely been encouraged by politicians and public policies. Elected leaders decry health care costs until they can cut ribbons and add jobs. And Medicare provider payment policies, which have long set the standard for the private insurance sector, promote higher payments for procedural services than for cognitive ones, discourage team-based care, and reward service volume over population health.

There are signs, however, of an increasing recognition that big buildings are no substitute for cost-effective population-based care. In the past two years, six states have joined pioneers Rhode Island and Oregon in passing measures to assess current and appropriate levels of primary care spending in their state. Of course, increased primary care spending is necessary but not sufficient by itself. The Center for Medicare and Medicaid Innovation’s payment reform efforts continue to enjoy bipartisan support and are showing modest positive effects, with primary care–based groups showing the best performance. Employers and employees are becoming more aware that their premiums and cost sharing have been disproportionately financing the health care building boom, as research shows the differential between commercial and Medicare hospital payment rates continues to grow.

The slice of the US health care pie devoted to primary care is now being defined, and the evidence for expanding it continues to grow. The new buildings are impressive and the views are dazzling, but our country and its residents are better served by primary care than palaces.