A New Day for Primary Care

Whenever I tell people here at Stanford that I have been newly hired to help expand primary care, I usually encounter incredulity followed by sympathy (if they like me). They say, "But Stanford isn't interested in primary care. Did you know…" And what follows is usually some tidbit that illustrates how implausible the proposition is. For example, "Did you know that all the staff and faculty go to PAMF?" Or as one chair said, "Stanford primary care? That's an oxymoron."

My usual answer is that this is a new day. I tell them I believe there are three reasons why Stanford wants and needs primary care today. The first is strategic survival. Stanford has always been about leading-edge tertiary and quaternary care (and no doubt quintinary care will soon be invented here as well, if Harvard doesn't beat us to it). In the past, that was more than enough to ensure Stanford's success, both financially and intellectually. Primary care meant treating colds and high blood pressure. Granted, someone had to do it, but let it not be Stanford! 

However, as our local health care market matures, and hospitals merge and affiliate, they are increasingly regionalizing specialty referrals and procedures, and developing the competencies previously only available from academic medical centers such as Stanford. Physicians are increasingly joining large groups and cartels that direct their patients to the hospital and specialists that are a part of their system. 

Stanford will probably always have the most cutting-edge treatments for the most serious and rarest of conditions. But that alone may not be enough to maintain the size and the revenue we need to remain vibrant. While Stanford currently receives a large portion of its referrals from outside the local area, we want and need to ensure that we also have a base of local primary care physicians, both faculty and affiliated network partners, to refer patients and support the core research and the teaching missions of the institution. Simply put, we need a minimum scale to ensure sufficient downstream referrals.

At a more nuanced level, however, Stanford needs primary care so that we can be a cradle-to-grave health system that can help solve the problems of health care today. Just having doctors and referrals will not be enough if we are not actively pursuing the Institute for Healthcare Improvement's "triple aim" of improving the patient experience, improving the health of populations and reducing the cost of health care. With health care now consuming 18 percent of GDP (and rising annually); the U.S. spending approximately double the amount, per capita, of the next highest-spending industrialized nation; and with health outcomes rated by the WHO as 37th (ahead of Slovenia, but behind Costa Rica), society needs new answers. 

New payment mechanisms will be increasingly focused on driving quality, improving the patient experience and lowering costs. And whether it is through bundled payment, value-based purchasing, global capitation or accountable care organizations, Stanford has to provide the full spectrum of care — from primary care to acute hospital care to rehab and skilled nursing — to be able to fully participate in designing the solutions of the future.

You can't reduce hospital readmissions if you have no primary care system to coordinate discharges with; you can't reduce emergency department utilization if you don't have alternative, less expensive places for patients to go; you can't optimally manage end-of-life care if the doctor whom the patient has trusted most for twenty years is not part of the discussion and hasn't laid the groundwork with patients and families well before their final crisis. More broadly speaking, the only way that we, as a society, will be able to afford the miracles coming out of the medical research pipeline is by reducing waste, becoming more efficient and helping patients make good decisions — both for their lifestyles and for their health care.

Finally, Stanford has always been a thought leader in every important social problem facing society. Today, the burning platform is health care. With the recruitment of national thought leaders like Arnie Milstein, MD, and Alan Glaseroff, MD, Stanford has declared its intent to help lead the way. Now, through the collaborative efforts of the Hospital & Clinics' CEO and the Dean of the School of Medicine, Stanford is radically redesigning primary care (described in the accompanying article) as further evidence of its commitment to not follow, but to lead. Indeed, the purpose of a truly great university is to help solve the greatest problems of the day. If we are to succeed, it will take the combined will and commitment of our entire academic community.  

So if you run into me in the halls or at grand rounds, rather than sympathy, I'll expect the shared excitement of starting a vital new endeavor together. For me, it's an honor and privilege.

By Sang-ick Chang, MD, MPH, Assistant Dean of Clinical Affairs, featured contributor

Sang-ick Chang, MD, MPH, is a longtime primary-care physician who has served as chief medical officer for two of the San Francisco Bay Area's largest public medical centers. He was named to the newly created position of assistant dean for clinical affairs at the School of Medicine in August, 2012. As a noted expert in developing and managing regional primary-care systems, Dr. Chang is tasked with the job of strengthening primary care at Stanford Hospital & Clinic.