Care Is an Action, Not a Transaction

“Oh, those kids? Well, the school across the street doesn’t have a playground. They asked if their students could come here for recess, and we said, ‘Sure.’”

I was trooping around the flagship site of the largest community health center in Rhode Island. My tour guide, the chief medical officer, was pointing to a group of children playing on a strip of grass outside one the buildings in the complex, which is a converted commercial printing plant. We went inside and he showed me two floors of dental operatories. In a neighboring building, a warren of workstations was home to a colony of community health workers hired to do population health management as the community health center had embarked on its journey as a Medicaid accountable care organization.

The center’s complex was a considerable improvement from the site I first visited almost 25 years ago. The buildings back then were drafty, open collections of molded-plastic-seat waiting areas that resembled bus stations and cramped, dated examination rooms.

Now compare this comprehensive model of community-based primary care with the one that retail giant (and fellow Rhode Island-based corporation) CVS is expected to pursue. CVS wants to go big on primary care, envisioning hundreds of physician-led primary care centers as part of a revised store footprint more focused on medical care than motor oil.

CVS is not alone in discovering primary care. Drugstore rivals Walmart and Walgreens are similarly investing in the service. Venture capital is chasing the lucrative (and wholly publicly funded) Medicare Advantage market. Primary care is at the center of most of those strategies, which are delivered by practices partnering with or established by companies like Aledade and Iora Health.

There is gold in them primary care hills, these folks are realizing. Whether your business model is focused on building consumer loyalty, or reducing excess utilization, at only 5% to 7% of the health care budget, high-quality primary care builds great trusting relationships and exercises enormous leverage over the remainder of the health care pie.

What’s more the number of chronically ill Medicare beneficiaries — the people most in need of the care coordination that high-quality, team-based primary care can deliver — who report that they have a usual source of care is actually declining. Shouldn’t primary care and population health advocates, long forsaken in favor of their better-reimbursed specialty siblings, welcome the attention of these well-financed suitors?

Maybe. It depends, I think, on who is being served and how.

Does primary care, and by extension all of health care, exist to meet the needs of the community or the individual? The Rhode Island community health center’s hospitality to the school — unreimbursed and mentioned off handedly — was a response to a request from the community. More comprehensively, the center had patched together funding to expand its dental services after seeing the unmet needs (and hurting mouths) of their patients. The capital for all the health center’s investments has been slowly assembled from government, tax credited debt financing, and philanthropy.

Contrast this with an approach that looks to create and meet needs for untapped markets to generate financial returns for an investment of private capital, which could be easily deployed elsewhere. For CVS and venture capitalists, patients are consumers with varying needs and resources who shop in a market. Issues of personal or community fairness and equity are not their concerns, and returns are compressed to a calculus that undervalues long-term benefit.

More fundamentally, is the provision of care itself an act of service or a transaction? The term “care” is used promiscuously in our economy: from “Care Bears” to “hospice care.” At its core, however, to care for someone is to bestow one’s concern, time, and skills on another who is weakened and vulnerable. It has a foundational component of personal sacrifice and selflessness. Care is delivered with a respect for the relationship of the caregiver to the care receiver, and awareness of eventual reciprocity: sooner or later we will all be care receivers.

Those are not the attributes of a freely negotiated transaction between similarly situated customers and suppliers.

In the United States, we are a long way from being a society oriented toward health care that meets the needs of the community through acts of service. Our sources of financial capital see too much of an investment opportunity in the industry to submit to that idea.

But the principles of community and service remain in health care. The response to the COVID-19 pandemic in our country — flawed as it has been — has rested on the private sector doing the bidding of the community (for a fee, to be certain). CVS and its like are putting shots in arms. And we repeatedly salute the acts of selflessness from overworked health care clinicians and support staff.

Moreover, the majority of health care is financed by the government and that share is increasing. (It is entirely our tax payments that private capital is trying to capture.) So long as a third party is paying for it, health care is not a real transaction. But so long as the public sector paying for it, the community is involved in health care — the kids deserve places to play. And so long as personal sacrifice is involved in health care, the act of service remains.