- The challenges facing American healthcare are substantial, but today's guest says they all stem from long simmering issues in primary care.

He's Dr.

Troy Brennan this week on "Story in the Public Square."

(lively music) (lively music continues) (lively music continues) Hello and welcome to "Story in the Public Square" where storytelling meets public affairs.

I'm Jim Ludes from the Pell Center at Salve Regina University.

- And I'm G. Wayne Miller, also with Salve's Pell Center.

- And our guest this week is Dr.

Troy Brennan, adjunct professor at the Harvard T.H.

Chan School of Public Health.

He's also the author of a new book, "Wonderful and Broken: The Complex Reality "of Primary Care in the United States."

He's joining us today from Boston.

Troy, thank you so much for being with us.

- Thank you for having me.

- Well, and congratulations.

I mentioned to you, the book, it's tremendous.

It's an important read.

It's a timely read.

But before we get to that, let's talk a little bit.

You've had a really wonderful, varied career in healthcare, in a clinical setting, in the corporate world and in academia.

What's your overall assessment of the state of healthcare in the United States today?

- Like most people in health policy, I think my assessment's not a strong one of the United States healthcare system.

We spend a lot more money than any other country in the world on healthcare on a per capita basis, and yet we get much poorer outcomes than many other developed countries do.

So I think there's a lot of room for improvement.

- Well, and the real focus of" Wonderful and Broken" is the primary care sector in healthcare.

Do you wanna give us a quick overview of the book and then we'll get into it in some depth?

- Yeah, the book's about, well, sort of what's going on in primary care today, what's wrong, what could be right, what successes are there, what next steps do we need to take?

So I basically went out and visited with probably 40 or 50 different primary care practices and talked to people over the course of a two to three-year period of time about the nature of their practice.

And what I was looking for was to see places where people are providing what I considered to be value-based care.

That is care that's not on a fee-for-service basis, but rather care that's meant to take care of the entire population paid on a prepayment or per capita approach, so-called capitation.

And I found that there was a lot of places that are moving towards that, and a lot of places that are using that model today.

And that I think they provide lessons for what we can see as a healthcare system in the future that's based on primary care.

But I also have to go over the current state of primary care, which is not good.

The doctor and nurse practitioners and physician associates with the major clinicians, they're not happy.

They're getting burned out, they're not well paid, and many of them don't see a good future for primary care.

- So Troy, what prompted you to write this now?

I mean, you've written many, many books, articles, you've got a long list of publications in many, many places.

What prompted you to write this now at this point in history?

- Well, I'm looking back on, you know, sort of my own career and sort of following health policy over the course of the last 40 or 50 years.

And I think the major question about our healthcare system is that everybody in the United States and in other countries believes that a well-functioning primary care system is critical to a well-functioning healthcare system.

So primary care is the base, the foundation, the core of healthcare, and yet here in the United States, it's underpaid and overwhelmed, and people are not going into primary care.

So it's a incredible sort of paradox, very ironic that the very thing that we really need in the United States, strong primary care, is the very thing that we don't have.

- You make the case in your book, and you make it very, very strongly that if more people regularly saw a primary care provider, thousands of lives and billions of dollars would be saved.

First, why don't more people get care from a primary care provider, if they get that care at all?

- Well, I think a lot of people don't have access to good primary care, and the system doesn't necessarily sort of promote having a primary care physician.

And the way in which most primary care physicians are paid on a fee-for-service basis leads them to run clinics where they have to see 20 or 30 people a day, and they can't really provide the kind of care that's necessary for many individuals.

In a good functioning healthcare system with great primary care, the doctor has a long-term continuous relationship with the patient and basically sort of mentors and guides the patient, trying to avoid and prevent illness.

That's really what we wanna see out of primary care, but that's not the kind of primary care we can provide for most people in the United States today.

- So why do providers have so many people that they're caring for, the ones who are practicing?

You mentioned, I think 20.

- Well, I think, you know, the average primary care practice is step back.

The way, overwhelmingly in the United States, that we pay for healthcare is on a piece basis.

It's a matter of somebody provides a service and then they get paid for that service.

And the service that the primary care doctor provides is an evaluation and then management.

That's the name of the codes that they use to get paid, evaluation management.

But those codes don't pay very well.

Most insurance companies don't offer much money associated with those codes.

So in order to make a practice be financially viable, you have to see lots of patients.

And so people will see 15, 20, 25 patients a day in order to make enough money to feel like they're getting paid a reasonable amount.

A fee-for-service system doesn't promote the kind of primary care that I'm interested in, a value-based primary care where people are really trying to look out over the long term for an individual's interest.

And if the patient's sick, then they need to spend more time with the patient.

In the practices that are doing that, you know, what you'll see is people seeing 8 to 10 patients a day and being very careful in terms of calculating what the next steps should be for those individuals.

- Yeah, Troy, I find this fascinating.

I can remember as a kid, you know, my mom worked in healthcare, and I think doctors in our home were respected, maybe even revered.

But I think that was true of the community that I grew up in as well where they were sort of pillars of the community.

How did we get to a spot now where primary care physicians are burned out, as you described them, and feeling overworked and frankly undercompensated?

- Well, mostly in terms of the way in which we pay 'em, so that, you know, this system, as I suggested, the fee-for-service system causes this kind of assembly line approach to primary care, and the physicians begin to burn out.

You know, I've talked to physicians.

I remember talking to one physician who had worked in a fee-for-service approach for the first 10 years of his career, and then the second 10 years worked at Kaiser Permanente.

And he said the changes were dramatic in terms of the number of patients he saw and the satisfaction overall with his professional life, and also including his pay.

And it's because Kaiser Permanente operates on a system where people pay up front through the insurance company and then the doctors are salaried rather than being paid on a fee-for-service basis.

And they're paid to make sure those patients stay healthy, avoid illnesses, get out of hospitals quickly, stay out of the hospitals, and as a result, have overall lower costs of care.

- So Troy, a big piece of this puzzle, as it were, is medical school.

And if you're in medical school, and you're looking at your future, part of your future is gonna be paying back debt.

For most people at medical school, they come out of medical school with a boatload of debt.

As they look around at the specialties they might have, they don't see the payback in primary care.

They might go for surgery, they might go for any number of other specialties that pay more.

Talk about that, please.

That again is a critical, critical piece here.

- Yeah, it's true.

I mean, you can make three times as much going into especially like orthopedic surgery or cardiac surgery as you would in primary care.

One quote I like is that an ophthalmologist earns something like 8 to 10 times as much per hour as a primary care physician does.

So if you're a a medical student, you're accumulating debt and you're looking around what to do.

Primary care can be a very gratifying field for many individuals, but people have to do a calculation based on sort of where they would make a reasonable living.

And as a result, primary care is not as attractive as it once was or really should be I'd say.

Part of that is laid at the feet of the way in which we go about calculating how much doctors should be paid.

There's actually a committee that's run by the American Medical Association called the Relative Value Scales Update Committee.

We start to get rather technical here, but this committee, which is known as the RUC, according to its acronym, values how much individual services that doctors provide should be paid.

And they've always, at least from the primary care doctor's point of view, undervalued primary care.

And that's something that needs to change.

- You know, so I think about the way healthcare is delivered now too.

You also factor in nurse practitioners and physician's assistants.

Is there a piece for that?

I mean, if we talk about moving towards a value-based system, does that change the way healthcare is delivered for most consumers?

Or what are we ultimately getting at here?

- Well, it's true.

As you look at primary care today, the workforce is increasingly made up of nurse practitioners and physician associates.

And many people who I talk to think that's what the future means.

Many primary care providers will be trained as nurse practitioners or physician associates.

And those people do a fine job.

They don't get as much training in medical school, and they don't have real residency as the medical students do.

They don't get as long a training.

And they don't get the practical training that medical students get when they go into residency.

So in many places, you find that there has to be sort of on-the-job training for nurse practitioners and physician associates, but all that literature suggests that they do a very good job, in many ways equal to what the average doctor does in terms of providing primary care.

And as you think about the future with more information available through artificial intelligence techniques, people practice, what we say, they practice at the top of their license.

And practicing at the top of the license means that nurse practitioners and physician associates can every day do a much better job.

So can physicians.

So I don't think that there's anything there that sort of threatens primary care.

Many people and many studies of this has shown that nurse practitioners in particular provide a sort of human touch in primary care that's essential, and do a better job of that than many physicians do.

So the workforce is gonna change, but I don't think that changes the dynamic of primary care so much.

The major thing that has to change is the way in which we sort of pay people, and set up the practices.

- Can you talk about the input played by federal and state governments because they have a role in this as well?

- Yeah, I kind of set up the book in terms of looking at the various different influences on primary care.

And I talk about the federal government, I talk about the state governments, I talk about large insurance companies, small insurance companies, and even private equity in terms of their support for primary care.

With regard to the federal government, you know, the federal government, first of all, funds a great deal of primary care through the Medicare and Medicaid programs.

And we face a crisis in much of primary care today as we look forward to substantial cuts in Medicaid as a result of the so-called BBB Act, the Big Beautiful Bill Act that was recently passed in Congress at the behest of the Trump administration.

The federal government also plays a big role in the training programs in terms of funding training programs, and also in terms of the ways in which medical school is articulated.

So there are some levers in each of those areas to be able to sort of improve primary care.

The states, on the other hand, they mostly play, you know, in a paradoxical way, their biggest play is in Medicaid, which is a federal program, but it's a state federal program.

The states have a reasonable amount of control about the way in which the Medicaid program is administered in their states.

And there's a lot of states, I look in particular at Massachusetts, Oregon, Rhode Island, and Vermont at the way in which the states have taken steps to sort of reorder health policy and come up with a rational system for both paying primary care and supporting primary care.

And I think some of these states are doing an excellent job in that regard.

- Yeah, Troy, the book is not really so much about the changes in the technology supporting healthcare, but you made reference to it in the book and you referenced it already once today, artificial intelligence and what that portends for the delivery of primary care, particularly the kind of models that you're talking about here.

What's that look like, and what are the risks associated with it?

- Well, a big complaint that primary care doctors have today is that they're chained to their electronic medical record, that there's so much information sort of coming through, and then there are portals for patients to be sort of asking questions.

And then every specialist who sees a patient gets back to the primary care doctor and expects the primary care doctor to deal with a variety of different kinds of problems, including the prior authorizations from insurance companies.

And so people feel like they practice 12 hours in the office and they have another four or five hours left when they go home to be able to sort of catch up on everything that's come through the electronic medical record.

A lot of that can be made better through artificial intelligence.

Artificial intelligence can answer certain kinds of queries, can provide assistance for physicians in terms of the steps needed to be taken for patients that they've just seen, and can also, quite frankly, provide the documentation when the patient's being seen in the office.

There's now programs that will basically produce a note, a progress note on the patient at the time that the interview's finished based on sort of the ambient listening it's been doing.

So all these things have real promise in primary care.

I can't think of another area in commerce, quite frankly, where I think artificial intelligence can play such a salutary role as it could play in primary care.

Now, like everywhere else, there's problems with hallucinations and inaccuracies associated with artificial intelligence.

And so it's gonna require oversight by physicians, but I think it's going to make physicians, especially primary care physicians, much more efficient and in many ways take away a lot of the sort of drudgery work that they have to do themselves.

So I'm very bullish, as I think many people are, about the hopes for artificial intelligence and primary care.

- You know, just thinking about the first 15 minutes of our conversation here, and I think it's easy for us to gravitate towards the broken part of "Wonderful and Broken."

What's the wonderful part about primary care right now?

- Well, I'd say the wonderful part is the people who are providing it.

I mean, I went out and probably talked to 3 or 400 people who were direct clinicians, and a lot of people who were around the edges, administrators and patients.

And what you find is, you know, that even the most beleaguered individual primary care doctor or nurse practitioner still has highest regard for their patients, is doing what they're doing because they love patients, and they wanna take care of 'em, and they wanna provide the proper care.

So the wonderful thing is the human aspect of it.

It still exists and it's still very strong.

And that's why you get so upset about the fact that some of the factors supporting it are broken because here are really good human beings caring for other human beings when they really need it, and yet not supported by our healthcare system.

But that is the wonderful part.

- So getting back to the broken part, do you have any sense that the Trump administration is aware of this crisis and willing to do anything about it?

- Well, yes, they are.

You know, it's always difficult to make predictions about the Trump administration generally, and the healthcare aspects of it kind of in particular.

So they have identified this problem with leaving the valuation of services in the hands of the American Medical Association.

And they've said, at least in rulemaking that they've set forth, that they're going to change the way in which the so-called RUC plays a role in setting those prices for the services the physicians provide.

They're gonna move away from the survey methodology that the RUC has used for the last 30 years, but it's not clear exactly what they're gonna do.

They've also put in so-called efficiency adjustment factor, which should shift some money from specialists towards generalists, and in particular towards primary care.

I don't think it's gonna be enough that it's gonna be a substantial change, at least at this point.

The statistic that I'd like to cite is that in many European countries, 10 to 15% of healthcare dollars go to primary care.

In the United States, in Medicare, it's about 3.5%, and in commercial insurance, probably just over 4%.

So if this efficiency adjustment increases primary care pay by 3 to 4 or 5%, it's still not moving up the total substantially.

The other bad thing is that, you know, and this is the way it is with the Trump health administration, you go one step forward but two steps back.

They're going to really wound some of the most vulnerable parts of the system through the cutbacks in Medicaid and through the lack of premium support in the Affordable Care Act exchange market.

So you'll see substantial dollars going out of the system, and especially for impoverished individuals and people without insurance who rely, for example, on federally qualified health centers, they're going to be extremely at risk.

And, you know, people have begun to estimate the morbidity associated with that.

You know, unnecessary deaths will occur as a result of insurance not being available for people.

One thing that I like to talk about, you know, like no doctor, no nurse practitioner is trained for a situation in which their patient can't afford medical care.

They're not trained to like try to work around the need for a patient to see a specialist.

You know, you're trained if they have a particular problem, send them to a specialist who can deal with it.

But if you have an uninsured patient, you can't do that.

And so the doctors get extremely frustrated and this causes real burnout.

And that, in some ways, pales in comparison to the desperation that that individual who's uninsured feels when they've got something wrong with them and they can't afford to get care.

So, you know, we're gonna see a lot more of that unfortunately as a result of cuts that the Trump administration has put in place.

So overall, for my primary care, it's a negative.

- You know, healthcare has been a fraught political topic in this country for generations now.

But I'm just gonna go right at this, and you can laugh at me, but I'm just gonna ask it.

Single payer, a national health service model, would that solve the kinds of problems that you're talking about in "Wonderful and Broken?"

- Well, look, you know, I come at it from the point of view, I worked for big medical centers, then I worked for big insurance companies and PBMs, so, you know, I'm not somebody who would naturally sort of come at it from the point of view of sort of offering a single payer program.

When I talk to primary care doctors, by and large, I'd say overwhelming majority of them think we should have a single payer program.

And the single payer program would pay primary care doctors reasonably.

In a book I wrote that came out last year, you know, I make the prediction that we're going to go to a government-sponsored approach that maybe eliminate the private insurance companies, that's the single payer program, or you may go with a Medicare Advantage-type approach where the for-profit insurance companies and regional insurance companies are still involved.

But, you know, the way I see it long term, the guts of our system, which is based on employer paying simply can't continue.

You know, there's too much stress in that system.

So, you know, a long-term view is that we will get to a government-run program, whether it's a single payer or a government-run program like Medicare Advantage is today.

- Troy, you mentioned that a number of European countries invest far more in primary care.

Culturally, what makes them get there as opposed to where we are, where we don't invest that?

Why do they do it?

Why don't we?

- They've got a bit more rationality in their systems.

You know, most of the systems are either run by the government in a single payer format, or the government oversees the insurance companies that do pay for the care.

So there's a lot more rational planning associated with the approach in Europe.

And there's a lot less focus on, you know, trying to make as much money as possible in a fee-for-service system.

So, you know, you don't make that much more money if you're a cardiologist in Germany than you do as a primary care doctor.

So they've supported and matured their primary care.

And in so doing they're only following the science.

You know, science is very good that a strong relationship with a primary care doctor will lead to better outcomes for a patient and overall lower costs for the healthcare system.

So we lack that kind of rationality in the United States.

- Yeah, Troy, at the end of all this, you still emerge as an optimist about the future of primary care.

What's the source for that optimism?

- The people.

I mean, you know, the first thing is the people because, you know, no matter how bad it is, there's a lot of people who really wanna go into primary care and provide this special relationship to individual patients.

And they're good people, they're altruistic people, they're caring people.

So I think that there's gonna be that workforce sort of available.

And what I do in sort of going through what the feds have done, what the states are doing, some states, what the insurers are trying to do, you know, I see a lot of people promoting a better approach to primary care.

So I think that that will grow and mature.

And I think as these changes have to occur in the way in which we finance healthcare, primary care will have a real renaissance.

- Is that change though in how we finance healthcare?

Does that require government intervention or will the market ultimately make some of these shifts, even if we can't find consensus politically?

- No, I think it's gonna require... It requires government oversight.

The market... It's a complicated answer.

It will require some government oversight but that's not to say that market forces can't see that a better approach to primary care leads to better outcomes and lower costs.

And so there are individuals, private equity firms that can see the importance and potential profiting from promoting primary care because if you can offer a product that's a better product and a lower cost product, then that's a product people are going to be interested in buying.

So that's why I think that the market does play a role.

I'm not, you know, somebody who says we need to first have a single payer program, and then that will promote primary care.

There's a lot of market forces pushing in the right direction today.

But overall, there's still gonna need to be government intervention.

- Dr.

Troy Brennan, the book is "Wonderful and Broken."

Thank you for sharing it with us today.

But that is all the time we have this week.

If you wanna know more about the show, you can find us on social media or visit us at salve.edu/pellcenter where you can always catch up on previous episodes.

For Wayne, I'm Jim asking you to join us again next time for more "Story in the Public Square."

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