“A Paradox Persists When the Paradigm Is Wrong”: Pisacano Scholars' Reflections from the Inaugural Starfield Summit
=======================================================================================================================

* Noemi Doohan
* Anastasia J. Coutinho
* Jennifer Lochner
* Diana Wohler
* Jennifer DeVoe

## Abstract

The inaugural Starfield Summit was hosted in April 2016 by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care with additional partners and sponsors, including the Pisacano Leadership Foundation (PLF). The Summit addressed critical topics in primary care and health care delivery, including payment, measurement, and team-based care. Invited participants included an interdisciplinary group of pediatricians, family physicians, internists, behaviorists, trainees, researchers, and advocates. Among the family physicians invited were both current and past PLF (Pisacano) scholars. After the Summit, a small group of current and past Pisacano scholars formed a writing group to reflect on and summarize key lessons and conclusions from the Summit. A Summit participant's statement, “a paradox persists when the paradigm is wrong,” became a repeated theme regarding the paradox of primary care within the context of the health care system in the United States. The Summit energized participants to renew their commitment to Dr. Starfield's 4 C's of Primary Care (first contact access, continuity, comprehensiveness, and care coordination) and to the Quadruple Aim (quality, value, and patient and physician satisfaction) and to continue to explore how primary care can best shape the future of the nation's health care system.

*   Family Practice
*   Forecasting
*   Leadership
*   Personal Satisfaction
*   Physicians
*   Family
*   Primary Health Care
*   Research Personnel
*   Writing

Amid cherry blossoms in Washington DC (April 23 to 26, 2016), 146 invited primary care experts and advocates gathered in honor of one of the greatest researchers in primary care—Barbara Starfield. The inaugural Starfield Summit was hosted and organized by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care and cosponsored by the American Board of Family Medicine Foundation, the Pisacano Leadership Foundation (PLF), and Family Medicine for America's Health. The website ([www.starfieldsummit.com](http://www.starfieldsummit.com)) hosts detailed information and resources from the Summit, including the list of attendees and speakers. The Summit aimed to focus discussion on critical topics in primary care and health care delivery, including payment, measurement, and team-based care. Invited participants included an interdisciplinary group of pediatricians, family physicians, internists, behaviorists, trainees, researchers, and advocates. Among the family physicians invited were both current and past PLF (Pisacano) scholars.

## Summit Structure and Discussion Process

The invited speakers presented 20-minute “Big Idea” presentations (in the style of TED Talks1) discussing each of 3 featured topic domains (payment, measurement, and team-based care), which were followed by small-group breakout sessions (fashioned after the World Café method2). The break-out sessions were structured into 4 predetermined interprofessional discussion groups that remained constant throughout the entire conference.

Speakers, matched with 2 colleagues assigned to assist in framing and leading discussion in these groups, rotated among the 4 discussion groups. During discussions, written notes were taken by Pisacano scholars and are being used to create the content for multiple dissemination reports, including this Article. The Summit culminated with a Congressional Forum in the US Capitol Visitor's Center.3 Summit attendees paid their own way to the event; in some cases, individuals received full or partial sponsorship from their supporting organizations.

Appendix 1 lists the Summit attendees and includes asterisks next to the names of the Pisacano Scholars who acted as note-takers during the break-out sessions. The described format for discussion allowed themes to develop within groups, which were shared at multiple levels throughout the Summit. This historic Summit garnered a high level of expertise, energy, and enthusiasm for primary care and inspired conversations regarding primary care's role in health care systems—past, present, and future. Based on the success of this first Summit, future Starfield Summits are being planned.

## PLF and Its Role in the Summit

The PLF, created by the American Board of Family Medicine in 1991 to identify and develop leaders in family medicine, awards the Pisacano Scholarship to a small group of medical student leaders entering the discipline of family medicine each year. In addition to scholarship funding provided to current scholars throughout their residency training, current and past (alumni) Scholars have the opportunity to participate in an annual leadership symposium. In 2016, the PLF held its annual symposium as a preconference to the inaugural Starfield Summit, bringing together a diverse group of Pisacano scholars and alumni, including policy leaders, academics, practicing physicians, and family medicine trainees. Eighteen current Pisacano Scholars and 21 Pisacano Scholar alumni attended the Starfield Summit, which had 146 total invited attendees. Following the Pisacano symposium and the Starfield Summit, the authors formed a writing group to summarize highlights from the Summit and to contribute to ongoing conversations around the future of primary care in the United States.

## Overview of the Summit Discussions: “A Paradox Persists When the Paradigm is Wrong”

During the pre-Summit PLF symposium, Pisacano scholars and alumni were introduced to the Starfield Summit topics to prepare for discussion about the state of primary care in the United States. In response, Pisacano Scholar Dr. Justin Mutter remarked, “a paradox persists when the paradigm is wrong.” This comment became a theme repeated throughout the Summit, given that we considered the paradox of primary care within the context of our current health care system.

### What is the Paradox?

Primary care is better at improving the health of the forest than of the trees. Dr. Kurt Stange explored this paradox and summarized numerous studies illustrating that when primary care teams are measured by care for individual diseases, primary care performance is inferior to specialty care with regard to disease-specific outcomes and adherence to disease-specific guidelines and recommendations.4 However, in ecological studies, improved population health outcomes are associated with a larger, stronger, and more integrated primary care system.4,5

The Starfield Summit explored several additional paradoxes relevant to primary care. Although the United States spends more on health care than other high-income countries, we have poorer health outcomes.5 These outcomes are thought to have been driven by a historic lack of commitment to social services and primary care.6 In the United States, clinical care is responsible for only 14% of health status7,8, but accounts for 95% of US health care costs.9 Furthermore, the United States is the only high-income country without a publicly funded universal health system6 and 9% of Americans remain without insurance.10

### What is the Paradigm?

In our current system, fee-for-service reimbursement and productivity models reward the administration of tests, procedures, and medications aimed at treating individual diseases,11 with minimal reimbursement for coordinated services that consider the whole patient in the context of their community. This disease-centered paradigm creates vertical medical silos focusing on specific organ systems and illnesses. Without an incentive for holistic treatment and without measures for comprehensive care, integration across care domains is often not prioritized. Further, a critical aspect of health care delivery—the relationship between provider and patient—has been devalued, as evidenced by shorter primary care visits and inconsistent reimbursement for care coordination and asynchronous care services (eg, phone calls, emails),12⇓–14 which are capable of strengthening connections and increasing “touches” between patients and primary care teams. Current systems of care are fragmented, force patients to choose specific in-network providers, and provide few resources for delivering preventive health care services or addressing the social determinants of health.15 Without a radical shift in care delivery and payment to adequately address the upstream causes of illness, sustainability of preventive services and coordinated chronic disease management is threatened. Continuation of the current paradigm will lead to escalation of health care costs without the assurance of improved actual health of individuals and of populations.

### Is a Paradigm Shift on the Horizon?

In a ground-breaking decision to move the United States away from fee-for-service reimbursement and toward value-based payment, Congress passed the Medicare Access & CHIP Reauthorization Act (MACRA) in April 2015. MACRA attempts to alter the way in which Medicare will pay for services, including ending the sustainable growth rate formula for how Medicare payments were previously determined, creating a new framework for paying health care providers for comprehensive care, and establishing new quality metrics.16 Although this new system shows promise, specific details about these payment mechanisms and quality reporting have yet to be released. Without established standards, MACRA leaves primary care leaders wondering how value-based payments will change health care delivery. Will the current measurement and delivery infrastructures remain or will value-based payments encourage and incentivize innovative delivery models? Will primary care's emphasis on whole-person wellness and population health be adequately valued or is the paradigm shifting only incrementally from fee-for-(individual) service to fee-for-(individual) measurement? Will the financial viability and, thus, the long-term survival of primary care become more certain or will it continue to be threatened? Can our health care system reach a place where a healthier forest equates to healthier trees?

### What Would Be a True Paradigm Shift?

The 2016 Starfield Summit created an opportunity to examine primary care bright spots, disruptive innovations, policy-relevant issues, and research priorities. New primary care ideas arose and old ideas re-emerged. Participants envisioned a new US health care system in which the strengths of both primary and specialty care could be combined with public and behavioral health to emphasize better quality of care, greater whole-person wellbeing, improved population health outcomes, and improved physician satisfaction. Together we envisioned a paradigm shift in which a redesigned system of delivery, payment, and measurement could energize the primary care workforce and create a structure for improved health outcomes for the individuals and populations of our nation. The 3 tables included list “brainstorming themes” that emerged from the discussion of each of the 3 featured topic domains (payment, measurement, and team-based care) and include representative statements from these discussions.

## Summarizing the Summit: Facts, Discussion Themes, and Authors' Thoughts

### 1) Payment: Breaking Down Vertical Silos of Care, Creating Global Budgets

Although the Summit could not define a scalable payment model for the entire US health care system and the primary care function, several themes regarding important elements of an effective payment system arose in Summit discussions and are summarized in Table 1. Several presenters highlighted the limitations of our current payment structures and the need for broader support of primary care services. Systems of payment based on fee-for-service reimbursement favor procedures and specialists, driving health care into vertical medical silos and promoting volume of services over value. This trajectory inhibits the improvement of primary care and the financial sustainability of the health care system.11,17 Despite inherent problems in the fee-for-service model, it can be valuable if restructured to place higher fees on services that support improvement in overall health outcomes rather than individual disease states and when used for low-cost and underutilized services such as vaccines.11 Alternative models that incorporate different payment schemes are being implemented across the country. Summit participants discussed advantages and disadvantages of these models and how some experiments show promise for the future. For example, the state of Maryland created global budgets in which hospitals partnered with the Centers for Medicare and Medicaid Services to abolish fee-for-service payments and replace them with a global funding structure, creating the first hospital risk-adjusted rate regulation system.18 This transformed payment model allows hospitals to focus on outcomes and value while maintaining financial stability. In the first year alone, Maryland saved Medicare $116 million while reducing the rate of potentially preventable conditions by 26.3%.19 In Rhode Island, a policy change created a mandated increase in primary care expenditures to 10% of total health care expenditures, leading to a savings of over $100 million in its first 4 years.20 Rather than simply increasing fee-for-service rates for primary care services, payers were required to instead invest in other primary care resources such as care management, behavioral health services, and increased health information exchange. Summit participants also learned about a disruptive payment innovation, Direct Primary Care (DPC), and about how DPC organizations such as Qliance, Iora Health, and One Medical Group are changing the traditional paradigm through per-member payment models that allow flexibility in service delivery.21⇓⇓–24 These new payment paradigms require clinical leaders, employers, and patients to come together in unique ways. MACRA may also help to shift these payment paradigms, but it is too soon to predict whether it will inspire the radical change needed for transformation.

View this table:
[Table 1.](http://www.jabfm.org/content/29/6/793/T1)

Table 1. 
Brainstorming Themes Regarding Payment Discussed at the 2016 Starfield Summit

Innovations in financing and delivery of health care provide hope and direction for the future, but many questions remain. Which of these payment and delivery models will work to provide the best health outcomes and will be scalable on a national level? Perhaps the best answers will emerge, as in Maryland and Rhode Island, by turning to individual states for solutions that will create a healthier America. To determine which of these payment systems has the most potential, we must begin to create metrics that capture outputs relevant to primary care.

### 2) Measurement: Are We Measuring What Matters Most?

Summit discussions around pay-for-performance included some positive comments regarding its value in individual disease-based evaluation and reimbursement, while drawing attention to important limitations. It remains unclear how to measure components of care delivery that influence broader health outcomes, especially in complex patients. Table 2 summarizes themes that emerged from the Summit discussions regarding the quality metrics that can be used, or need to be developed, to assess the ability of primary care to change health outcomes and improve population health.

View this table:
[Table 2.](http://www.jabfm.org/content/29/6/793/T2)

Table 2. 
Brainstorming Themes Regarding Measurement Discussed at the 2016 Starfield Summit

A variety of Summit talks explored what we know about measuring the primary care function.

Currently $15.4 billion is spent annually on monitoring quality.25 Professor Amanda Howe, an academic general practitioner from the United Kingdom (UK) and the incoming president of the World Organization of Family Doctors (Wonca), shared a cautionary tale of how an initiative to measure and reward primary care quality across the UK (the Quality Outcomes Framework [QOF]) did not have the consequences it intended.26 The QOF attempted to provide value-based payments to physicians, but its multiple disease-based metrics supported process driven rather than outcomes-based care. Over time it tended to fragment the way primary health care was delivered, rather than improving whole-person or population care. This contributed to a decline in physician satisfaction with the QOF, and there was no overall measurable improvement in health inequities.26

Measuring clinics on their ability to maintain optimal access and a comprehensive array of services are 2 examples of ways in which metrics can support some of the features of primary care that are thought to underlie the value it brings to patients and health systems.27,28 Another aspect of primary care that is difficult to measure, but arguably the most personally meaningful, is the effect of a therapeutic relationship with a consistent clinician.13,14 Although not all aspects of clinical practice can be measured, metric reform has the potential to truly transform primary care delivery.

Quality metrics and subsequent payments that incentivize and support the primary care function have the potential to affect individual and population health. However, radically shifting the current measurement paradigm presents challenges including the difficult tasks of development, implementation, and evaluation of metrics that lead to improved outcomes and are relevant to patients. In addition to capturing important primary care functions, measurement needs to account for social vulnerabilities so that quality can be evaluated in the context of the social determinants of health and health disparities.

### 3) Team-Based Care: Revisiting and Revitalizing Old Models

Summit discussions yielded consensus that teams are critical for the success of the primary care function. Table 3 reflects themes that came out of the varied discussions on the topics of teams. Summit participants examined roadmaps for transforming primary care practices with team-based approaches. Examples highlighted included the 10 Building Blocks of High-Performing Primary Care,29 team strategies for integrating behavioral health and primary care,30 incorporating patients and communities into primary care teams (eg, community health workers),31 and approaches for increasing joy in practice.32 Participants concluded that effective teams must be adaptable with regard to the needs of the population, size of the community, and specific roles of team members.33⇓–35 The patient as a vital team member must remain at the center of all team activities. Team-based care must also exist across specialties and locations of the health system (eg, clinic, emergency department, hospital), and community engagement as a form of team care is crucial.

View this table:
[Table 3.](http://www.jabfm.org/content/29/6/793/T3)

Table 3. 
Brainstorming Themes Regarding Team-Based Care Discussed at the 2016 Starfield Summit

Team-based care can improve access to a broad scope of primary care for individuals and communities. For example, team members can share routine well-care and preventive care tasks (eg, referrals for cancer screenings, immunization forecasting) as well as care coordination and education, enabling clinicians to see fewer, but more complex, patients per day for longer visits and freeing time for additional leadership and administrative tasks.36⇓⇓⇓–40 Although team-based approaches have improved efficiency and quality in many studies41, they have shown limited effect on addressing social determinants of health and connecting patients with specialty care.42

Sidney and Emily Kark, the founders of community-oriented primary care, incorporated community needs assessments, population health data, community health workers, and multi-disciplinary teams using community-oriented, team-based approaches in the rural South African Pholela Health Centre during the 1940s.43 As the paradigm continues to shift away from volume-based care and toward teams, we should revisit these and other pioneering models of integrated primary care, public health, and behavioral health. Patient-Centered Medical Homes with patient navigators, health coaches, integrated behavioral health, and daily huddles are also reemerging as a path to improved care.44

## Discussion

The Starfield Summit renewed our commitment to Dr. Starfield's 4 C's of Primary Care (first contact access, continuity, comprehensiveness, and care coordination)45 and to the Quadruple Aim (quality, value, and patient and physician satisfaction).46 If the current payment paradigm persists, our health care system will continue to be dominated by competition and profit instead of collaboration on behalf of our patients and communities. We must move to a payment system accountable for improved health outcomes with careful attention to social and clinical vulnerabilities to ensure that health disparities narrow, not widen. These outcomes must include evidence-based, whole person–centered, comprehensive metrics in addition to those that are disease centered. This will require the development, implementation, and evaluation of methods for measuring the outcomes that matter most in primary care and population health. Models of team-based care must be reinvigorated and reinvented in today's world.

### Importance of Primary Care Research

The teachings and research of Dr. Starfield are both reassuring and inspiring as we continue along this path to radically shifting entrenched paradigms. Starfield's rigorous work throughout the world illustrated how strong primary care foundations contribute to better health for populations at lower costs.5,47 Her work also demonstrated the need for sustained infrastructure to support primary care and health systems delivery research—infrastructure that supports our best and brightest scientists and infrastructure that facilitates future innovation and discovery that can be scaled to serve populations.48,49 By building and strengthening 21st century primary care laboratories, we can rigorously evaluate innovative care models and expanded primary care financing and delivery systems.49 As evidence mounts, it can inform better policies and accelerate the transformation of primary care and the health system as a whole. A central premise of the Starfield Summit, which needs to be tested, is that positive change in health care will occur when researchers, policy makers, and clinicians work together to design and execute high-quality primary care research, and implement and disseminate the resulting best practices.

## Conclusion

Now is a time of opportunity to build on the foundational evidence created by Dr. Starfield, deepening our discoveries of how primary care can most optimally affect the future of health and health care delivery in this country Following in Dr. Starfield's footsteps and standing on the shoulders of primary care giants, we will courageously continue to study, learn, practice, and shift the paradigm until the paradox fails to exist.

## Acknowledgments

The authors gratefully acknowledge formatting assistance from Sonja Likumahuwa-Ackman and Rebecca Luoh of Oregon Health Sciences University Family Medicine department.

## Appendix 1

List of Attendees at Starfield Summit (from [http://www.starfieldsummit.com/documents/](http://www.starfieldsummit.com/documents/))

*   *Indicates Pisacano Scholar notetaker

*   Larry Anderson

*   Bengt Arnetz

*   *Kathleen Barnes

*   Andrew Bazemore

*   Darcy Benedict

*   *Paige Bennett

*   Robert Berenson

*   Arlene Bierman

*   Mary Beth Bigley

*   Jonathan Blum

*   Elizabeth Brown

*   Shannon Brownlee

*   Jennifer Carroll

*   Bob Cattoi

*   Agnes Cawi

*   Steve Cha

*   Candice Chen

*   Frederick Chen

*   *Maggie Chen

*   Marshall Chin

*   Megan Coffman

*   Jonathan Cohn

*   Steve Cook

*   *Anastasia Coutinho

*   Ardis Davis

*   Jennifer Devoe

*   *Trevor Dickey

*   Perry Dickinson

*   Noemi Doohan

*   Robert Dribbon

*   Marguarite Duane

*   Elizabeth Enschede

*   Kim Epperson

*   Rebecca Etz

*   Bernard Ewigman

*   Blake Fagan

*   Rushika Fernandopulle

*   *Jillian Fickenscher

*   Terry Findlay

*   Michael Fine

*   Anne Gaglioti

*   Nicole Gastala

*   Valerie Gilchrist

*   Rick Glazier

*   Stephanie Gold

*   English Gonzalez

*   Larry Green

*   Robert Hall

*   *Seneca Harberger

*   Sandra Hassink

*   Carolyn Hewson

*   Amanda Howe

*   Lauren Hughes

*   Elizabeth Hutchinson

*   Jane Ireland

*   Yalda Jabbarpour

*   Susan Jackson

*   Paul James

*   *Jonathan Jimenez

*   Lara Jirmanus

*   Samuel Jones

*   Douglas Kamerow

*   Art Kaufman

*   Christina Kelly

*   Ali Khan

*   Kristen Kimbrel

*   *Nathan Kittle

*   Kathleen Klink

*   Keith Knepp

*   Chris Koller

*   Stanley Kozakowski

*   Meredith Kratzmann

*   Alex Krist

*   Allana Krolikowski

*   Anton Kuzel

*   Lisa LeRoy

*   Lenny Lessor

*   Evelyn Lewis&Clark

*   Winston Liaw

*   Kenneth Lin

*   Steven Lin

*   Kurt Lindberg

*   Jennifer Lochner

*   Theodore Long

*   *Elizabeth Looney

*   Daniel Lowenstein

*   Sean Lucan

*   Rebecca Luoh

*   Laura Makaroff

*   Marie Mann

*   Jason Marker

*   Paul Martin

*   *Sara Martin

*   Amy Matheny

*   Kristine McCoy

*   Lloyd Michener

*   Benjamin Miller

*   Miranda Moore

*   Andrew Morris-Singer

*   Fitz Mullan

*   *Justin Mutter

*   Sharon Nabaka

*   Krishman Narasimhan

*   Marci Nielsen

*   Marc Nivet

*   Terri Nordin

*   Eleni O'Donovan

*   Nwando Olayiwola

*   Ann O'Malley

*   Kavita Patel

*   Lars Peterson

*   Bob Phillips

*   Russell Phillips

*   Claire Pomeroy

*   Maria Portela-Martinez

*   James Puffer

*   Casey Quinlan

*   Melanie Raffoul

*   *David Rebedew

*   Eugene Rich

*   Brad Richards

*   Diane Rittenhouse

*   *Max Romano

*   Dana Safran

*   Dave Schmitz

*   Laura Sessums

*   Manisha Sharma

*   *Alyssa Shell

*   Scott Shipman

*   Kurt Stange

*   Glen Stream

*   Erin Sullivan

*   Robyn Tamblyn

*   *Kenji Taylor

*   Sebastian Tong

*   Doug Tynan

*   Olga Valdman

*   Kara Walker

*   Jane Weida

*   Nicholas Weida

*   Thomas Weida

*   Therese Wetterman

*   Peter Wingrove

*   *Diana Wohler

*   Shale Wong

*   Julie Wood

## Notes

*   This article was externally peer reviewed.

*   *Funding:* none.

*   *Conflict of interest:* none declared.

*   Received for publication July 16, 2016.
*   Revision received August 26, 2016.
*   Accepted for publication September 6, 2016.

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