Reinventing Primary Care to Improve the Lives of Seniors and the Physicians Who Treat Them

There is a need for new care models that reduce PCP caseloads while addressing the complex needs of older patients, says Vivek Garg, M.D., CMO of Humana’s Primary Care Organization. It has also made many primary care physicians’ jobs untenable, resulting in excessive patient caseloads and insufficient time and resources to focus on individual patient care and the myriad issues affecting their health. There is a clear need for new models of care that reduce PCP caseloads and administrative work while addressing the complex health and social needs of older patients, particularly those living in underserved communities. A value-based, care team approach, providing community-based senior-focused primary care is showing benefits for both clinicians and their patients. To provide effective care, it’s essential to meet patients in the context of their daily lives – knowing the communities they live in and understanding and addressing the multiple factors impacting their health. Recent modifications to Medicare Advantage plans have expanded the definition of supplemental benefits to address a variety of social service needs; the push toward value-based care has also significantly elevated the role of SDOH in treating patients given the outsized impact they have on health outcomes.

Providing comprehensive, whole-person care requires a team of practitioners who can address the patient’s medical and social needs, along with a payment model that rewards them for the quality of care they provide, not for the quantity of services rendered. According to studies on time demands on physicians, primary care doctors need 18 hours a day to fulfill all their responsibilities, leaving scarce minutes for each patient visit. Supported by a team of practitioners, including pharmacists, nurse care coaches, social workers and behavioral specialists, the physician not only has more time to spend with their patients, but the team can also address a full spectrum of patient needs that the physician alone cannot possibly do. Using a value-based, care team model has substantially reduced physicians’ patient panels, enabling PCPs to spend an average of 40 minutes with a patient and increasing the frequency of their visits. However, when physicians have more time with patients, they are better able to identify potential mental health challenges and can provide easy access to mental health services when a behavioral health practitioner is an integral part of the primary care team, eliminating major obstacles to treatment.