A Global Look at Primary Care in the Era of COVID-19

Friday, October 30, 2020
REUTERS/Sergio Perez

Head of the Health Division, Organization for Economic Cooperation and Development

Senior Fellow for Global Health, Council on Foreign Relations; President and CEO, Resolve to Save Lives, an Initiative of Vital Strategies; Former Director, Centers for Disease Control and Prevention; @DrTomFrieden

Vice President, International Health Policy and Practice Innovations, Commonwealth Fund


Senior Policy Fellow, Robert J. Margolis Center for Health Policy, Duke University

Panelists examine challenges and best practices in providing primary care around the world, the vitality of access to primary care, and how healthcare settings have evolved in the era of COVID-19.

DENTZER: Thank you very much and welcome to everyone today for this very important discussion on primary care. Primary care is first contact care. It's meant to be the first door into the health-care system when you're sick. And ideally, it's an open door to people who will work very hard to keep you healthy. It's supposed to be where you go for an examination or a consultation, then if needed, you're referred on to secondary care from a specialist, tertiary care from a sophisticated hospital, or even quaternary care where you might get into a cancer clinical trial, for example. That's supposed to be the way the system works in most of the places around the world and we sent you a number of links in the context of the invitation of this meeting that reflects on all of that.

Back in September of 1978, in Alma-Ata in Kazakhstan, the World Health Organization held a very important international conference on primary care. And at the end of that conference, it issued a declaration that said that primary care is essential health care, it should be universally accessible at affordable cost, and it should be not just part of a country's health-care system, but part of the overall social and economic development of communities. Now, at the time, the WHO had a very expansive definition of primary care. It said that it had a role in public health in promoting a healthy food supply in nutrition and sanitation, in maternal and child health and family planning, and prevention and control of infectious disease. The Alma-Ata Declaration also called on all governments to form national policies and strategies to launch and sustain primary care, especially in developing countries.

So today, we're here almost fifty years after Alma-Ata to talk about the challenge of continuing to meet the goals of the Alma-Ata Declaration. There are a lot of important questions on how much countries spend on primary care as a share of their total health spending, how they structure primary care in terms of the delivery of it, how effective their delivery care systems are, and how important they are particularly in the context of a global pandemic. So I'm delighted to introduce our discussants today. First of all, we'll be here with senior fellow of the Council, Dr. Thomas Frieden; Francesca Colombo of the Organization of Economic Co-operation and Development; and Reginald Williams of the Commonwealth Fund. And, Tom, we're going to ask you to start us off today. Where is primary care in 2020, forty-eight years after Alma-Ata? What's the evidence that it improves health? And where does the situation stand with respect to the adequacy and robustness of primary care around the world?

FRIEDEN: What we see is that with very few exceptions, primary care is the poor relation in the health-care system. There are a handful of countries around the world that are getting it right. But most of us, including certainly most of the United States, is not. And the result of that is that we're not getting the kind of health value for our health dollars that we could get. Primary care is both the most effective and the most neglected part of our health-care system. Primary care fundamentally is about addressing the needs of the individual in the context of their family and community and thinking about prevention. I think in the midst of the COVID-19 pandemic, we recognize the weakness of public health systems in many countries of the world, but what is less apparent is the weakness of primary care. And what you're seeing in parts of the world is an exacerbation of that. Whether it was in China, a flocking to hospitals because people didn't trust primary care, or in the U.S. where there's been the bankruptcy of many primary care practices because our model of payment is basically piecework. If people come in, the doctor gets paid; if people don't come in, the doctor doesn't get paid. Now, that doesn't mean that if you get healthier, the doctor gets paid more. So we have a very irrational system if you're trying to maximize health. So you have to step back and be a little more analytic and say, there must be a reason that most countries in the world are failing to invest adequately in primary health care. That reason is not because it doesn't work or it's controversial. It works and people like it. That reason is really about economics, that we're structuring our health-care system to maximize economic returns, maybe to pharmaceutical companies, maybe to hospitals, maybe to large insurance companies. What you see in the U.S. is as people were too scared to go into their primary practitioners, insurance companies made a fortune because they didn't have to pay the doctors. Doctors went bankrupt and patients didn't get the care they needed. This is kind of, in a nutshell, the irrationality of health-care financing in the U.S. and in many countries around the world. But there is a way forward. We know that investing in primary health care saves money and saves lives. So I look forward to learning with the others on the panel and hearing the questions that are asked so we can think about how this can become a true teachable moment, an inflection point, so that we're focused on using our health-care system, of all crazy things, to maximize health.

DENTZER: Francesca, your organization, the OECD, has really put forward numbers behind what Tom said, which is that primary care is the poor relation in most health-care systems. I believe you all have reported that only 14 percent of total health-care spending is devoted to primary care among the thirty-seven OECD member countries. Why is that, given that as OECD has also pointed out the returns on investment in primary care are so high?

COLOMBO: I think there's a fundamental issue of valuing primary health care. As you said, only 14 percent of total health spending is devoted to primary health care across the OECD countries, which are by and large, the advanced economies across the world. But if we take out dental care, for example, we go to something like only 8 percent of it. I think there is in general, this reflects also that poor value that is put on the profession, the GP profession, the primary care physician profession, relative to other professionals. So if we look at the gap on remunerations, for example, the gap goes in the order of magnitude of one by two between the remuneration that goes to a GP and the remuneration that goes to a specialist across a wide range of OECD countries. And over time, that remuneration gap between the primary care profession and the specialist has been actually growing over time. So we feel somehow there is more attractiveness instead, which could be relative to the prestige, perhaps specialties offered to primary health care. The fact that specialist care that's considered more prestigious, and then it's linked also to the remunerations that goes into onto that. I think there is a further economic gap, which has to do with the fact that primary health care is asked to do more and more with aging societies, with growing chronic conditions where the patients, which is more complex, there is no patient in like really in primary health care. And so in front of these growing complexities of primary health care, we have not equipped them with the right sets of resources both financially, there are some economic incentives to try to give some sort of pay for performance or odds on payments to facilitate coordination, for example, or to facilitate better management of chronic conditions, but also in terms of providing resources such as information infrastructure that can really keep primary health care being better linked with specialist care centers, facilitating a real-time generation to information, which really shows the picture of the patient across the whole pathway of care. I think it’s a matter of payments, but not just in terms of financial payment, it’s also a matter of resources in terms of things like digital technologies, for example, and fundamentally in terms of skills.

DENTZER: So, Reggie, the Commonwealth Fund has done international comparisons, particularly among the rich countries, of how various aspects of health care go, including, of course, primary care, and we see a lot of variety in the way primary care is delivered around the world. Even just Francesca mentioned GPs, general practitioners, we call them different things in different parts of the world. We don't use GPs here. We call them family doctors or internists or what have you. So there is a lot of variety. What does that variety show, what has emerged from the Commonwealth Fund studies on this topic?

WILLIAMS: Yes, in our studies and trying to understand things like primary care and how it's best delivered from around the world, we've learned a few things. One, that primary care that involves multidisciplinary teams, including health workers, tends to be the best.  Care that supports integration with public health, social services, and even behavioral health are particularly important. And even before times of COVID, using virtual care, telemedicine, mobile and digital health, data-enabled ways to manage care, become particularly important. But there's also that element of community-based engagement. When you look at countries, for example, like the UK and the Netherlands, that has some of the strongest primary health-care systems, practically everyone in the country is connected to a primary health-care provider. And those are long-standing relationships that are developed over time. There's an ability to know a person, help coordinate and triage their needs, and really do things like home visits or have after-hours care to engage people so that they don't go to the emergency room or delay care. We know that one of the biggest reasons that people in the United States delay care is related to cost barriers. And in many other countries and systems there's a removal of caution for primary care visits, people are encouraged to engage at that level. So I could go on with many examples from other countries, but I think this kind of integrated approach it seeks to really meet a person within the community is something that we really see being successful.

DENTZER: It is striking in the latest Commonwealth Fund survey, even on areas like home visits, the U.S. rates at the bottom among all countries. Primary care doctors typically do not make home visits, whereas that's very typical in other parts of the world.

WILLIAMS: Very much so. When you look at our international survey, it's really shown that people do not have that usual source of care, they do not have access to the care after hours. And the use of technology to get access to care is really a new phenomenon. And so there's a lot of opportunity to look at community-based primary care models that involve nurses, community health workers, make sure that digital technologies are providing data and information to people to better manage their care, and interchange that information and exchange it with their providers. There's still more than can be done in the United States to make our primary care better.

DENTZER: Tom, there are some global bright spots here, yet, in particularly in some developing countries, what are those and what are the lessons we can take away from those?

FRIEDEN: There are several—Costa Rica, Cuba, Thailand, Sri Lanka, some others. Thailand is a very interesting story. Because starting nearly forty years ago, the concept that health care would be a right and available to all and focused on primary care really became something that was nonpartisan—it was widely accepted. If you think about the U.S. for a moment, we accept without questioning that every child at least K through 12, and ideally, pre-K through 12 and through college, has a right to an education regardless of the ability to pay and then it should be of a certain quality. We really don't have that consensus in the U.S. when it comes to primary care and in a way that shocking because it's life and death. So the Thai experience is instructive in that through many political changes, really whipsawing from one political party to another, military rule, civilian rule, through all of it, that societal commitment to primary care has been there. And to an extent you see that in the United Kingdom as well, you see it in some other countries where the health service, if it is delivering value, becomes something that's treasured by the populace. Now, there's one number that I'm just so struck by in Thailand. They've got a population of about sixty million people. And they have one million health volunteers who work in the primary health care centers. They're paid so volunteer is a relative term, but they're paid. And they're community workers basically. They might go out and bring someone in, deliver medicines to someone's home, take a blood pressure, encourage someone to come back, measure blood pressures in the waiting area, do health education. That's one out of sixty people in the whole country serves as a volunteer in their primary care system.

And if you think about it, Reggie Williams discussed the importance of team-based care. And that's clearly going to be one of the ways forward. I think of it as at least a triple win. If you can have nurses, pharmacists, health volunteers doing more in the health-care system, first off, the cost of care comes down. Second, the nearness to the clients, the patients get better. And third, quality gets better. And fourth, employment gets better. So it's kind of a quadruple win, and something that we really need to expand in this country and throughout the world.

And I'll also mention, as Reggie also mentioned, about telemedicine and digital tools. This is one area where we're seeing rapid progress in the U.S. And the question is, whether that's going to just regress, as things go back toward normal or be an on-ramp to a much better digitally connected experience where patients can access their providers 24/7, get answers to questions, have a televisit, video visit or in-person visit as needed. So we see the outlines of what a really effective primary care system could be in this country and around the world, but we're still so far from it.

DENTZER: And what an irony that, to some degree, we've only gotten there in the midst of a pandemic when we've relaxed a lot of the regulations and payment restrictions around telehealth. So Francesca, some countries again have made these larger investments. We know the UK a number of years ago took steps to raise pay for general practitioners, to mandate that they create 24/7 access for their patients, and that has resulted in a number of improvements. Are there other examples of countries that have taken those kinds of specific steps that serve as a lesson for the rest of the world?

COLOMBO: Yes, there are some other countries, although I should say that there is no country that has particularly good and excellent indicators on all fronts. But there are other countries like Israel, which has an excellent primary health-care services, particularly supported by an information infrastructure. It's called, QICH, if I remember correctly, the name is [the National Program for] Quality Indicators in Community Healthcare and really has a large number, more than thirty indicators of quality of health care particularly geared towards the preventative measures, but also the effective management of people with chronic conditions whether they have cancer, or diabetes, or hypertension, and so forth. And it's quite an impressive mechanism to monitor the performance of different providers for patients, which needs primary health care or access to primary health care. And it's also based on the way that they can benchmark also those performance indicators, identifying any shortfalls that might happen, and so forth. So that's basically, you know, that's one example of a country which is doing quite well.

The United Kingdom is always mentioned as a good country. A little bit, some of the Nordic countries. They have particularly in areas where there is a problem with distance, for example, with remote care that needs to be provided, like in Norway there is a very strong network or services which are available for digital technologies that preexisted the COVID-19 crisis, or even the use of different type of health professionals, community health workers, nurses in a more innovative way, for example. You know that is a way to solve some of the issues about the availability of resources in some countries.

The Netherlands was mentioned as also having very effective care services. One thing, which unlike of the Netherlands, for example, is this out of office, you know, a continuous twenty-four hours availability of primary health-care services. It can be obtained either through, you know, telephone contacts, or even having community services which are open twenty-four hours where there is always at least a GP, primary health-care doctors, and nurses and support so they work really as a team, but people can access that twenty-four hours. And this is tremendously powerful to avoid people getting into hospitals, for example, during weekends or during the night.

DENTZER: So, Reggie, we of course, know that the primary drivers of health status in life lie pretty much outside the health-care system and the social and economic determinants of health and there's been a slow, increeping realization of this basic fact at least in the United States, but in other countries as well, causing health-care systems to pay more attention to those forces, and doing that in large part in the United States, at least, by linking up with social services agencies. But that process isn't going all that well in the United States, in particular. How is it going among the other rich countries? How well are they connecting people with other needs that must be met, whether it's healthy food, better housing, etcetera, etcetera. What's primary care playing in that context, what role?

WILLIAMS: So when we look at other countries and how they perform in these areas, there's a greater focus on the social determinants of health and the way care is delivered. And that happens even in low- and middle-income countries. When there's a national priority, that primary care needs to be improved, you can see a lot of different benefits that take place. In the country like Costa Rica, where it was a national priority to improve primary care, you see social services and health care services being engaged and delivered alongside one another in primary care interaction visits. Where you can look to Brazil, where their national strategy focused on primary care. It's called the Family Health Strategy. And so there's this engagement around, again, food, housing, access to transportation, and even the integration of mental health, which we know is increasingly important as it relates to physical health outcomes that people are focused on.

DENTZER: And Reggie, I want to stand you and ask you one other question because we see a lot of data surveys now coming out of the United States about how much mistrust there is in the health-care system, particularly among vulnerable populations and along racial and ethnic lines. Black Americans, in particular, very deeply suspicious of that the health-care system is not sufficiently responsive to them. What do we know about that in relation to primary care? Does it also relate to their feelings about primary care, their experience of primary care, as well as to specialty and hospitalization and other aspects of health care?

WILLIAMS: Well, from our research, you know, I'm happy to report actually that there is good confidence in the ability of the health-care system to meet people's needs. Yes, we have health-care disparities. Yes, there are people that are discriminated in our health-care system. But by and large, people are happy with their care. There's more concern when it comes to the federal kind of government role and response. And I think a way to actually build on the strengths of both primary care and building trusting communities are to have more community-based health care services. You know, when you look at some of the models that exist across the globe, the primary health-care provider isn't a place you go to, it's somewhere next door. It's the physician you've known for a while. It's kind of that old hometown doctor that we all can kind of think of as a person who's known you for a while, knows the needs that your family has. Engaging with a physician like that or a primary care provider that's a part of your regular life, builds that trust. And so I think if we're going to improve the way we deliver primary care, we have to think about more localized neighborhood-based approaches that allow that trust to be built.

DENTZER: So Tom and Francesca, we've spoken about the great underinvestment in primary care in so many parts of the world. And Francesca, in particular, you talked about the big disparities in pay, what we pay, for example, primary care providers versus specialists. And as you said, it's roughly two to one—specialists in favor of primary care. In the market economies, where you don't have an effective National Health Service or a government actually mandating pay levels, what can be done to increase pay for primary care providers? Or is it really just going to be a function of pumping more money into the system and letting other resources develop to strengthen the system? As you said Francesca, the ability now of primary care practices to manage the multiple needs of chronically ill elderly people is immense. Do we have to be pay providers more do we just have to get more resources overall into the system? Francesca, we'll start with you. And then Tom, I'd love to hear your comment on that.

COLOMBO: Both, I mean you need to pay more, you know, otherwise, it’s a very legal attractiveness for the profession. That's one issue. And that requires arbitrating the resources that you have in the system or putting more resources into the system. Clearly across countries, there are many different levels of paying, many different levels of spending. But for me, one important point is the attractiveness of the primary health-care profession. Because that has to do, yes, with pay, but also with the way the recognition that this is given even in the context of the education system. So change goes to medical schools and the way the approach to the professional family health care, the way we train the doctors of the future there. It's fundamental. If there is still that idea that, you know, being a cardiologist is much more prestigious and being a GP is considered the poor cousin, well, even if you change the margins of the payments mechanism, even to dramatically change the payments, will do only half of the job. So I think you need to tackle both at the same time.

DENTZER: And to this question about how market economies can do that other than through some levers of federal policy—Medicare, Medicaid, etcetera. Tom, can you comment on that?

FRIEDEN: Well, I guess, I'd like to think it's not just the amount of pay. And I really appreciate Francesca's point about status. And I think about some of the best educational systems in the world. Some of the Nordic systems where, not only are teachers paid a lot more, but it's a very high-status job to be an educator. And it should be because we're entrusting our children to these individuals who are teaching. I think, similarly, recognition is important.

But I would add one more factor, which is not just what we pay, but how we pay. And there may not be a universal answer. But one thing that many of us are very interested in is paying that would be more of a per person per month payment. Now, that has risks because the risk is that care will be stinted on. So you have to include significant positive incentives and also some negative incentives. But you can imagine a way of doing that, you also have to have incentives for the physician and with the clinician, because it's not going to all be doctors, it will be nurse practitioners, it will be other individuals, other practitioners, physician assistants and others. But you really want to make a trade, you want to say to the primary care doctor or clinician, we're going to pay you X per member per month. And we're going to drastically reduce your paperwork, because you're spending 10 or 20 percent of your time doing useless things—fighting with insurance companies to get reimbursement or to refer your patients or other things. We're going to try to drastically reduce that burden. In exchange, we're going to look at quality.

And we've looked over the years at a very simple question. How can you save the most lives with health care? And the answer is actually quite simple. It's improved management of high blood pressure. High blood pressure is the leading preventable cause of death globally, more than ten million deaths a year globally. It's also probably the leading single cause of health inequalities in the U.S. Black Americans have about a 40 percent rate of hypertension versus about 30 percent for white Americans. And the rate of control is lower. So you're having most of your life expectancy difference, the plurality of it, from a poor management of blood pressure, but it's across the board. In the U.S., we made a huge effort to improve hypertension management and we failed. We went from 54 percent to 44 percent despite a lot of effort. You see Canada reached close to 70 percent with a focus on primary care. Thailand is not far from the U.S., it's somewhere around 40 percent now. The Nordics may be in the 70 percent range. Interesting with the United Kingdom, despite having very good access, is below 40 percent in its control rate, lower than the U.S. It's a question of focus. So you want to basically say to the primary care provider, we're going to pay you for keeping your patients healthy and you have to look at the incentives all across the line. So can you have shared savings? So if a primary care doctor puts intensive effort into managing someone and keeps them out of the hospital, they should gainshare some of that in a positive incentive. If on the other hand, they're referring inappropriately and treating inappropriately, they may not be allowed to enroll more patients and lose some income.

And then you also have to make it incentivized for the patient. You say to the patient, if you go to your primary care practitioner, no co-payments. The medications, at least on a core list are free, completely free. This business of user fees, we really have to get our minds around. It's very appropriate to have a user fee if you want to reduce your use—totally appropriate. If you want to increase use, you eliminate user fees, and that includes preventive care, preventive medications. It's just quite irrational. We had some progress there with the Affordable Care Act, where some cancer screening and preventive care was made completely free to patients. But then the system fought back and things like colonoscopy with polyp removal, which is a preventive measure, you ended up with huge co-payments for patients. So you've got to make the incentives for the doctors, for the system, and also for the patients to work so that we're maximizing health.

DENTZER: Great, thank you so much, Tom. Carrie, are you ready to introduce our question period?

Q: We'll take our first question from Sylvana Sinha.

COLOMBO: Hi, I'm Sylvana Sinha. I'm the founder and CEO of Praava Health, which is actually a network of family health centers in Bangladesh. My question is, in response to a comment Dr. Frieden that you made early on in the session relating to how insurance companies are benefiting from the fact that patients in the United States were not accessing primary care in the early days of the pandemic. So I'm sure that's true, but what we also know is that even insurance companies benefit when patients are active in primary care regularly financially, because if you can prevent disease before it escalates, then hospitalization rates go down. Right? And so I guess my macro question is, you know, how do we introduce these value-based care concepts at a systemic level? I mean, we're seeing in the United States and in companies like mine in Bangladesh, and in small ways, we're trying to introduce value-based care concepts...

DENTZER: Okay, I think we got the gist of that question. Tom, do you want to go ahead?

FRIEDEN: Yes. And thanks for the work that you're doing in Bangladesh. We're actually working with partners in Bangladesh to scale up hypertension treatment. When it comes to value-based care, hypertension has a huge burden of preventable stroke and heart attack. Bangladesh probably has it in the single digits for hypertension control and yet the medications can cost dollars a year and be done very effectively through a standardized approach. But I think your question was, so insurance companies should benefit if there's prevention and the problem is churning. I had a memorable conversation many years ago with the head of a large insurance company in New York City. And he said to me, quote, "We've studied it. The ROI [return on investment] of good diabetes care is positive. But it takes seven years to turn positive. And our average member is a member for four years. Therefore, I have a fiduciary responsibility not to give good care to my patients with diabetes."

I think unless we have the kind of consistency and standards, we have the perverse incentives of the market driving decisions that should be driven by health considerations. Now, there are certainly some market-based approaches that can support health progress and are really important health progress. But there are also ways in which the profit system is very inimical to having a health-based system. I'd be very interested in both Francesca and Reggie's thoughts about the same topic.

DENTZER: And I do want to ask Reggie about this because Reggie we certainly have some examples now in the United States of value-based payment approaches that appear to be engendering better primary care and lowering spending overall. We've had the entire array of accountable care organization experiments. We've had a number of patient-centered medical home experiments carried out under the aegis of the Medicare program here in the United States. And we have other entities, as Tom said earlier, that are essentially being paid on a capitated basis—Kaiser Permanente probably at the forefront among them—that are able to use the resources to pay primary care providers well, and provide the kind of different delivery system that we've been describing earlier, very digitally enabled via telehealth, etcetera. So what is your thought about spreading more of that and the degree to which we would be able, in the United States at least, to build up primary care through those mechanisms?

WILLIAMS: I think there's really a lot of opportunity in the United States to do this. Payment reform can really support primary care improvement. And I think that can happen in a couple of different ways. One, paying conditions differently in these value-based care kind of payment arrangements. There's been a lot of experimentation by the Medicare program, as you said, looking at ACOs, looking at medical home, looking at other ways in which you can provide these incentives. And I think there's great opportunity in doing that. But there's also the fact that we need to look at compensating physicians differently. Because there's been decades of underinvestment in primary care in the United States. So you know, if we are to say that improving primary care is a priority, then leveraging the power of the Medicare program is a way you can see the adoption of these models take place over the long term. And so hopefully, we'll be able to do that. It's happening in many different ways and local communities and through health plans in and out of the public and private sector. But we need a greater focus on introducing it broadly.

DENTZER: And I want to get Francesca's comment on the degree to which other countries are employing these value-based payment strategies. And then we'll take our next question. But Francesca, go ahead, please.

COLOMBO: Sure. Not as much. I mean I could say the one advantage of the United States is precisely the opportunity for innovation and experimentation that comes from the fact that you very more divide the system which is complex—different providers, different payment arrangements, different insurance. So that creates an opportunity for learning. Across the world, there are some experiments, but the difficulty that countries have is that you have a system at the national level, and it becomes more difficult to implement a big reform at the national level. Now, what happens is that you see some experimentation that is encouraged by the governments, of course, that is already building on a system which functions better, I would say, that already incentivize the coordination, the preventions at the system level in a better way. So productivity is less innovative. But the starting base is a system which is oriented towards a stronger family health-care system. What we see also is that there is quite a lot of experimentations using things like paper performance, innovations, or add-on payments for paying for things like coordinating care. Very often what these payment innovations are at the very beginning, is a payment for reporting better data. Because the question is what do you want to incentivize the system for? Very few indicators of true outcomes and quality are collected on a systematic basis across all the countries. And so a starting point of having the economic incentives is really to say, okay, this incentive is there, but you need to start collecting data in a different way.

DENTZER: And obviously that is the way a lot of things began in the United States as well. And let's go to our next question, Carrie.

STAFF: We'll take our next question from Kathy Ward.

Q: Hi. So my name is Kathy Ward and I'm with the World Bank. And I want to just start by thanking everyone on the panel but also the organizers. I think the fact that the Council on Foreign Relations is having a panel on this topic is fabulous and just a real sign of progress in terms of what we think is important to measure and focus on as we think about building a better world. So bravo to everyone. The question I have relates to technology, you know, AI, machine learning, all that sort of stuff. In the context, you know, of COVID, I've heard people say that we've made more progress on making better use of digital health and all the technology, you know, more progress in eight months than we did in, say, ten years in many situations. But I think it still feels like a Wild West in a lot of ways in terms of what gets used, what gets attention, how things get picked up and all that. And what I want to ask the panelists is looking at that sort of Wild West and also the gains that have been made in the context of COVID, looking particularly at primary health care in resource constrained settings, what do you think should be top of the agenda for us going forward? What gains that have been made during the COVID era do we need to lock down and expand? And what haven't we been looking at that needs to be atop of the agenda to move forward the primary health-care agenda? Over.

DENTZER: Well, a very important question. And Tom, what do we know about innovations, particularly in resource-constrained countries during the pandemic around, for example, telehealth, etcetera, other modalities of reaching people?

FRIEDEN: I think telehealth is the big deal here. I've been kind of groaning at some of the overpromising on whether it's AI or exposure notification tools, but telehealth is real. And you're seeing massive expansion. In both India and China, we've been working for multiple years with partners, and there's been a lot of resistance to it. And within weeks of COVID hitting, there was an open door. Now, there are still challenges. There are bandwidth challenges, confidentiality challenges, documentation challenges, software and hardware challenges, but telemedicine is showing a way forward. And one of the issues has to do with transcending geography. Even if you look in the U.S., what you have, Susan, you know, is a relaxation of some of the regulations that limit cross-state provision of care. Now, that's really interesting because that creates the potential for a pretty substantial increase in efficiency if you can have cross-state provision of care. The professions won't like it, the guilds won't like it, but if you can establish at least what is acceptable to do across boundaries, it's really important. It's not an unalloyed—it's not going to solve all of the problems because sometimes you do have to have a laying on of the hands for a medical visit. And also, documentation can be very challenging and how can you do it in a way that makes sure that patient confidentiality is assured. And a lot of times, the laws and regulations have not kept up with what's the practice. And so what's a reasonable regulatory framework that's workable and respects patient autonomy and rights and confidentiality, but isn't so bureaucratic that's going to make it impossible for the doctors or patients to care? The other area of telemedicine isn't just patient-clinician, it's also patient-nurse, patient-healthcare worker, clinician-nurse and clinician-team. So there's lots of ways to use these newer technologies to get rapid progress in improving both the access and the efficiency of primary care.

WILLIAMS: I think that's a really important point that you mentioned there. The idea of clinician condition or provider-provider communication is important because that's how you can use telehealth to access rural areas or areas where there may be high poverty or medically underserved populations by having that clinician connection. And the only other thing I would add is, I think we do have a lot of conversation about digital health that focuses on complex systems, AI, and the like. But we're seeing early examples of simple things like text messages and reminders that come to people's phones as a way to reengage people with primary care and preventive care in a time where people are not engaging with the health-care system because of fears associated with COVID. And so even low-tech solutions can provide a lot of opportunity to help people get the care they need.

FRIEDEN: And if I can just mention, one of the most exciting things we've done at Resolve [to Save Lives] over the last three years is to build an Android app called Simple, at on the net, which is free open-source, and we have a very, very good set of engineers have worked on it for years. It takes an average of fourteen seconds for the nurse to record a follow-up visit. And it provides essentially all of the information you need to manage hypertension, diabetes, both as a clinician and as a program. So I think there are some new technologies that are exciting leapfrog, even revolutionary.

DENTZER: They could point to just very simple things like chatbots that could help make the systems more efficient and reduce some of the administrative expenditures that in the U.S. are a particular issue. Francesca, please go ahead.

COLOMBO: Yes, sure. I mean, there's been three main inputs of accelerations in this area from my perspective. The first one really has to do with telemedicine and telehealth, and health systems across the world, but particularly, I would say high-income countries are incredibly rigid. They're structured in ways which have been set up for decades. And changing the way things are done, the relationship between patients and doctors and so forth is incredibly difficult. And in the context of this crisis, there have been really an acceleration to introduce for allowing new provider payments for clarifying regulation, for clarifying on how the teleconsultation can be paid, for creating new platforms for teleconsultations, and things like that. So that's the first area where there's been really an acceleration.

The second area is artificial intelligence. Obviously, there is a huge hype around artificial intelligence. There is possibly a lot more things that need to be done. Artificial intelligence can function to extend the U.S. good data, which is sufficiently standardized, which is sufficiently high quality that can go into a machine in a way that does not bias the results, for example. So chatbots are an example of something that can be done, can facilitate, or make the health system more patient-centered. Their opportunity to vertically accelerate innovations of thinking about new drugs, for example. I think there is a huge potential there are but possibly more hype and expectation than where we are really there at this stage. And the first accelerations that we see in this area has to do with the data, you know, the health data themselves, which are found across OECD countries, and most probably across the world, is at the moment not leveraged enough. So the value really of data comes by bringing together all the data generated across the health system, the hospital sector, the primary care, the lab, the long-term care systems, and so forth, leveraging all of that, bring it together at the individual level and linking that, which obviously requires having sufficiently privacy legislation for allowing the privacy and respectful use of the data. What we see in COVID, is that there's been an acceleration of some of that, particularly to help generate data across the health system linked at the individual level in a more real-time way, which was unprecedented before. And I think there is a huge opportunity there to continue to work on making those linkages possible, of course, in privacy and a respectful way.

DENTZER: And we should also note that there are increasingly AI-enabled technologies that, for example, allow nonspecialists to screen people for signs of diabetic retinopathy, so ironically, pushing care that is now delivered to the specialty level to the primary care setting. So we're just at the beginning of this transition. We'll see how far that goes. Let me remind the audience, we have time for perhaps one or two more questions. So if you do have a question, please pose that now.

As we think about the future, if we were to have another Alma-Ata conference, maybe next year, and issue another declaration that put together obviously some of the same themes that the first one did around investment, around the importance of primary care, what should be in a declaration like that to create a kind of a guiding light, a North Star, for the countries around the OECD and beyond, and in fact, throughout the world going forward? Tom, I know that's a big one but let's start you off on the first draft of Alma-Ata II. What do you say?

FRIEDEN: I'm not real big on declarations. I think they end up killing a lot of trees and not saving a lot of lives. And in fact, there is an Alma-Ata II, the Astana Declaration, which was released last year and frankly doesn't say much.

DENTZER: Okay, 3.0 then.

FRIEDEN: What we need is to be really concrete because ultimately, it's not that complicated. Every person should have a clinician. And every person should have a core set of high-value medical interventions provided to them including all the recommended vaccinations, effective reproductive care, effective developmental care, and I'm going to wave the flag here again on hypertension. It's really striking. Here we are in the U.S., we spend, what, $3.6 trillion on health care, and we get the single most important question right, less than half the time—44 percent of the time. And it's not just access. The UK gets it right about 36 percent of the time. So we've got to get beyond access to value. And I think that hypertension should be the pathfinder for that. It's a pathfinder for primary care because if you just stay with me for a moment, what we've realized in hypertension care, having now done this in dozens of countries, is that you can do it successfully if you do five things well.

First, you have an evidence-based protocol. And that can be quite simple. Kaiser Permanente uses it—algorithm-driven care—and there are simple ways to do it. It'll drive costs down and quality up. Second, that you have regular supply of medications and good quality blood pressure monitored. Third, that you have a patient-friendly approach. So you waive the barriers whether it's cost, or distance, or cultural. And fourth, that you have a team-based approach, because it's not going to be a doctor, it's going to be a team doing a good job. And fifth, you have an accountable information system, so you know what your hypertension control rate is because once you know that, you can improve it dramatically. And those five components of good hypertension control happen to be the good five components of every aspect of good primary care. Do you have patient-friendly, team-based, accountable, evidence-based, high-quality services? And so I would say let's use hypertension as the global pathfinder because we know if we can get the global control of hypertension up from 14 percent to 50 percent, we can save between one and two million lives every single year and many more strokes and heart attacks.

DENTZER: So, Tom, you introduced again the phrase team-based care. And the notion of having not just access to a clinician, but to a team, including potentially, as we've discussed earlier, a community health worker would seem very, very important. Reggie, what would be on your list for Alma-Ata 3.0, declaration or not, even if it's just meaningful action as opposed to worth?

WILLIAMS: Well, I would add some of the implementation steps that I think are important. One, kind of focusing on payment reform that really supports primary care, value-based payment and improving the compensation levels whether it's been under investment. Two, increasing the supply of primary care providers. That will be by adding different types of providers to the care team—that can be nurses, that can be community health workers. That could also be thinking about digital tools and others that can really create a broader team that meets the needs of people. And then the third is telemedicine. We've talked all about the gains that we've made. Let's make sure that we continue to make those gains once we put this pandemic behind us or learn how to live with it. Telemedicine is a potential way in which we can get care to more people more effectively. Those are my three.

DENTZER: And just quickly on the topic of the labor supply in primary care. We know very importantly that nurses and nurse practitioners play a very essential role have fought long and hard to get the ability to practice to the top of their licenses in various states without necessarily having to be doing that under the supervision of physicians. What else do we need to do to sort of free up other components of the labor supply, in the U.S. in particular, to continue to provide primary care? Reggie, that's for you?

WILLIAMS: Well, I think there's an opportunity to allow other people, other different providers, play a key role in managing the care. And so you can see not just your commissions, your primary care physician, your nurse and nurse practitioners, or your community health workers, but you can see the introduction of social workers and other professionals that are really actively engaged and looking to monitor and manage the care of people. When we did some research and we looked at how primary care was expanded to meet more people's needs in South Africa, it was a nurse-based approach. And so there are a wide variety of different ways we can ensure people get better care, but I think a team-based approach is vital to that.

DENTZER: And I think we would be remiss if we didn't also talk about the integration of behavioral health into primary care given that that is such an important component, in addition as a driver of other health issues and health expenditures. So I assume you would add behavioral health specialists to your list, Reggie, as well.

WILLIAMS: Oh, certainly. When you look at the opportunity in the integration that happens with behavioral health care, I put it right up there next to hypertension as a place where we would need to focus and ensure people get access to services. Because if you can treat the head, you can treat the heart, then you can treat the whole body. And so there's definitely opportunity there for more integration.

DENTZER: Okay, Francesca, we're going to give the last word to you on Alma-Ata 3.0 or plan of action across the world.

COLOMBO: Perhaps three things which have not been mentioned by the other speakers—the first one has to do with a very strong attention at the transition of care, the transition between the primary care and the hospital care settings or between the primary care and the long-term care, aged care sector, between primary care and the mental health sectors and support. There's a lot of value destruction, which happens in those transitions as the patient goes across the system. And I think there is a lot that can be done, whether for payment incentives or through better information on support that can be done, models of care that really can be done at that particular point.

The second one, I think there is a lot which needs to be done through primary health care, the responsibility to really empower patients to self-care of themselves. And health literacy, in particular, is very important in this context. You know, raising levels of health literacy for patients will have tremendous, you know, opportunities for improving the outcomes of patients, particularly those from low socioeconomic backgrounds, but not only. So I think there is a huge opportunity to put attention there. And of course, I mentioned already, but the issues of better measuring what we get out of the system is really poor what we get even internationally. What we have at the moment, our ability to measure primary health-care outcomes is mainly about not being admitted to hospitals. Those are the type of indicators that we have. We need to do a much better job at having indicators comparable internationally and to measure outcomes. It's actually a key priority for OECD. We have an initiative which is called the PARIS—Patient-Reported Indicator Surveys Initiative. It's not because we see these based in Paris, it's really a new international service to look at patient-reported outcome experiences in the incoming health care that we are working on.

DENTZER: Well, extremely important agendas that all three of you have laid out and echoing what of our questioners, I'd like to salute the Council for taking on this very important topic. And I know Tom, you had a premier role in getting it on to the agenda of the Council. I want to thank everybody who joined us on this call today. I thank our three discussants and presenters for a terrific conversation. Thank you so much.


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