Abstract
The second Starfield Summit was held in Portland, Oregon, in April 2017. The Summit addressed the role of primary care in advancing health equity by focusing on 4 key domains: social determinants of health in primary care, vulnerable populations, economics and policy, and social accountability. Invited participants represented an interdisciplinary group of primary care clinicians, researchers, educators, policymakers, community leaders, and trainees. The Pisacano Leadership Foundation was one of the Summit sponsors and held its annual leadership symposium in conjunction with the Summit, enabling several Pisacano Scholars to attend the Summit. After the Summit, a small group of current and former Pisacano Scholars formed a writing group to highlight key themes and implications for action discussed at the Summit. The Summit resonated as a call to action for primary care to move beyond identifying existing health inequities and toward the development of interventions that advance health equity, through education, research, and enhanced community partnerships. In doing so, the Summit aimed to build on the foundational work of Dr. Starfield, challenging us to explore the significant role of primary care in truly achieving health equity.
- Health Equity
- Leadership
- Primary Health Care
- Social Determinants of Health
- Social Responsibility
- Vulnerable Populations
From April 22 to 25, 2017, 181 primary care experts and advocates convened in Portland, Oregon, to share ideas during the second Starfield Summit. Named in honor of Professor Barbara Starfield, a pediatrician and health services researcher who devoted her career to advancing the role of primary care globally, the Starfield Summit aims to build on her legacy by optimizing the primary care function.1 Whereas the inaugural Starfield Summit in 2016 focused on payment, measurement, and new primary care models2, this second Summit focused on the role of primary care in achieving health equity.
The Summit was hosted and organized by OCHIN3 and the Department of Family Medicine at Oregon Health & Science University, and cosponsored by the American Board of Family Medicine Foundation, Family Medicine for America's Health, the North American Primary Care Research Group, and the Pisacano Leadership Foundation (PLF). Key documents and videos of speakers from the Starfield Summit are available online.4 Participants represented an interdisciplinary group and included primary care clinicians, researchers, educators, policymakers, community leaders, and trainees. Appendix 1 lists the Summit attendees.
Starfield Summit II Structure
Seventeen thought-leaders were invited to present 5-minute Ignite-style talks5 in 1 of 4 domains: social determinants of health (SDHs), vulnerable populations, economics and policy, and social accountability. The presentations stimulated discussion for future actions in 90-minute breakout sessions on each topic. Each speaker had a moderator to facilitate these discussions, during which themes and ideas for action were captured by designated note-takers. These insights were then shared with the larger group. On the final day, an action-planning meeting was held to identify next steps for integrating health equity work into primary care. Appendix 2 outlines the Summit schedule. A third Starfield Summit, addressing metrics in primary care, was held October 4 to 6, 2017.
The PLF and Its Role in the Summit
The PLF was created by the American Board of Family Medicine in 1991 to develop leaders in family medicine. It awards scholarships to medical students entering the specialty of family medicine and invites current and former scholars (alumni) to participate in an annual leadership symposium. A total of 32 current and former Pisacano Scholars attended the 2017 Summit. After the Pisacano symposium and the Summit, the authors—all Pisacano Scholars or alumni—formed a writing group to summarize highlights from the Summit and contribute to ongoing conversations about health equity and the future of primary care in the United States.
PLF Leadership Symposium: Community Organizing
The 2017 PLF symposium was held the day before the Summit and focused on community organizing as a mechanism to address health equity, a recommendation supported by the National Academies of Sciences, Engineering, and Medicine.6 The symposium was organized by Pisacano Scholars (Nathan Kittle, Glenna Martin, Brian Park), in partnership with the Industrial Areas Foundation (Joe Chrastil, Luis Manriquez), the nation's largest community organizing body.
Community organizing aims to build collective power by identifying shared issues and interests, mobilizing resources, and implementing collectively set solutions in order to create social change.7 It has demonstrated success in influencing social policies, including education8, housing9, and poverty10, and a recent initiative pointed to its impact on health.11 This approach was central to the original community health centers, leading to the development of cooperative farms, the creation of water sanitation systems, and the hiring of local residents to provide health professions pathways.12,13 As the funding for community health centers became more dependent on fees for clinical services, their missions narrowed toward providing medical care alone.13 The full-day symposium trained Pisacano Scholars and alumni in community organizing, promoting the revival of these skills in their communities.
Overview of the Summit Discussions
The idea that health is larger than the provision of health care is not new. In 1849, Rudolf Virchow, the founder of social medicine, said, “For if medicine is really to accomplish its great task, it must intervene in political and social life.”14 Primary care emerged to address health inequities by integrating clinical care, behavioral health, public health, and social services15; Drs. Emily and Sidney Kark developed the model of community-oriented primary care in rural South Africa in the 1940s16, the US Folsom Commission report established “health as a community affair,”17 and Family Medicine was founded on countercultural principles of distributive justice and SDHs.18,19 The responsibility of primary care in health equity evolved over subsequent decades to the 1978 World Health Assembly in Alma Ata, where Dr. Halfdan Mahler, of the World Health Organization, declared, “[Primary care] forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community.”20
A quarter century later, Dr. Starfield provided evidence to support the impact of the primary care function toward this social justice ethos, demonstrating that a strong primary care foundation is associated with improved health equity.21,22 In a moving tribute during the Summit's opening session, Dr. Starfield's husband, Dr. Tony Holtzman, Emeritus Professor of Pediatrics at Johns Hopkins University, emphasized that Dr. Starfield's work on health equity tripled after the turn of the century, representing 7% of her total peer-reviewed publications before 2000 and 20% afterward. Her work showed that within and across countries, strong primary care foundations attenuated the impact of socioeconomic disparities on health21,22 Yet, Dr. Starfield was aware of the limitations of health care alone in addressing health disparities, writing in one of those seminal pieces after 2000, “Inequity is built into health systems.”23
Professor David Williams, the keynote speaker at the Summit and a professor in public health and sociology at Harvard University, built on Dr. Starfield's critique, asserting that primary care has a responsibility to reach beyond health care and influence broader society in order to address health inequities. “Health care system reform,” Dr. Williams stated, “is critical, but insufficient” to improve our nation's health, given structural inequities in our society, including but not limited to biological weathering24, racial and ethnic differences in income25,26, and disparities in SAT scores by family income.27
Significant barriers exist for the primary care community to respond to Dr. Starfield's and Dr. Williams's charge to achieve health equity, including a fee-for-service payment model that promotes volume over value28, the increasing demands placed on primary care providers29,30, and the country's lack of investment in social services.31,32 The United States subsequently fails to close the gap in health outcomes and to achieve the triple aim—improved population health outcomes and patient experience of care at lower costs33—compared with other countries.34,35 These poor outcomes disproportionately burden minority and marginalized groups.36⇓–38
This Starfield Summit aimed to advance the foundational work of Dr. Starfield by highlighting primary care “bright spots” advancing health equity. Each bright spot was organized within 4 of the Summit's domains, and each answered an essential question regarding how the primary care community could address inequities:
SDH in primary care: If access to primary care alone is insufficient to address health equity39, what additional services can primary care systems provide to better address SDHs and improve outcomes?
Vulnerable populations: How can primary care partner with social services and community organizations to address unjust societal structures, thereby improving health?
Economics and policy: How do systems pay for and measure metrics that support a primary care infrastructure that addresses health equity?
Social accountability: How, and to whom, are primary care institutions held accountable for clinical services, education, research, and policies?
This report emphasizes key Summit bright spots and participant discussion themes, culminating with recommendations from the Pisacano writing group for how to promote effective SDH interventions that could be scaled to a variety of primary care settings.40
Summarizing the Summit: Facts, Themes, and Implications
SDHs in Primary Care
Primary care can play an instrumental role in identifying and addressing SDHs; key Summit themes supporting the role of primary care in SDHs are outlined in Table 1. Dr. Laura Gottlieb discussed how electronic health records (EHRs) enable social data to be monitored in clinical practice and offer the opportunity to address these factors at the point of care.41,42 Although many practices capture some social factors (eg, race/ethnicity, address, tobacco use), collection is not standardized, comprehensive, nor designed to affect care delivery.43,44 In response, the National Academy of Medicine recommended 11 social and behavioral domains to be collected and documented in EHRs, some of which are now recommended by multiple health organizations, including the American Academy of Pediatrics45 and the Center for Medicare & Medicaid Services Innovation Center.46
Brainstorming Themes Regarding Social Determinants of Health and Primary Care, as Discussed at the 2017 Starfield Summit
Furthermore, Dr. Lloyd Michener encouraged ingesting community-level data (“community vital signs”) into EHRs to better understand a patient's neighborhood context and potentially to guide the development of coordinated, multisectoral interventions.47,48 For example, the Just for Us program was launched after identifying increased needs of elderly patients in low-income housing in Durham, North Carolina49, partnering primary care, county health departments, and housing agencies to bridge clinical medicine with public health and social services. Other bright spots that were highlighted include documenting patient experiences in the EHR50 and supplementing monitoring patients' SDHs in the EHR, with social needs identified by community advisory councils.51 Summit speakers and participants recognized the need to prioritize which SDH-related metrics are most critical to monitor, to develop replicable interventions for patients screening positive for SDHs, and to test payment models that enable SDH activities in primary care.
Vulnerable Populations
Social determinants of equity refer to societal inequities in opportunities that lead to disparities.52 Populations classified as disabled53, immigrants54, rural55, and racial minorities56 were the select vulnerable groups discussed at the Summit, as outlined in Table 2. Dr. Somnath Saha further highlighted the ways in which multiple axes of social disadvantages (eg, gender, income, ethnicity)—also known as intersectionality57—compound health inequities.
Brainstorming Themes Regarding Vulnerable Populations, as Discussed at the 2017 Starfield Summit
Nearly every Summit speaker expressed a need to partner with community organizations to address policies upholding societal inequities. For this to happen, Dr. Denise Rodgers asserted that a paradigm shift—one where medicine views systemic and racial injustice as a health issue58—must occur first. She proposed that an initial step in this paradigm shift is critical self-consciousness58 of unjust structures in health care and society; educational tools such as implicit association tests could help providers identify prejudices59 and mitigate the impact of those biases at the patient level.60 Summit participants expressed this self-awareness to be a necessary precursor to applying a broader institutional equity lens that could eventually encourage antiracism training in medical education, equitable hiring policies within institutions, and analysis of intersectional identity data in research to gradually dismantle the determinants of equity.
Economics and Policy
The ability of primary care to effectively address upstream determinants of health depends on the capacity to pay for these interventions, as evidenced by the key themes outlined in Table 3. The predominant payment structure in the US health care system is driven by volume of clinical services (ie, fee for service) rather than value of care.28 The Affordable Care Act and, more recently, the Medicare Access and CHIP Reauthorization Act, encourage value-based care by supporting alternate payment models that shift toward prospective, capitated payments and may offer flexibility for practices to invest in interventions to alleviate disparities.61,62 Craig Hostetler explained how Oregon's involvement in the Comprehensive Primary Care Initiative63, which provided to clinics a risk-adjusted, capitated per-member per-month payment representing >80% of their revenue64, offered resources to expand primary care teams to screen for SDHs, implement novel SDH interventions, and partner with community organizations.
Brainstorming Themes Regarding Economics and Policy, as Discussed at the 2017 Starfield Summit
Risk-adjusted payments help guard against “cherry-picking” lower-complexity patients and/or underutilizing appropriate services in capitated models. Risk adjustments traditionally include individual-level risks, such as age and comorbidities, without accounting for social or community-level risk factors.65⇓⇓–68 Drs. Andrew Bazemore and Robert Phillips explained how payments that adjust for both patient-level SDHs and community vital signs43,48 could equip primary care physicians serving vulnerable populations with more resources to better address SDHs, pointing to the United Kingdom and New Zealand as bright spots that could guide and inform implementation in the United States.69,70
Social Accountability
As primary care interventions and payment models begin addressing SDHs, appropriate metrics are necessary to evaluate improvements toward health equity. Sonali Balajee discussed how social accountability—“the capacity to respond to society's priority health needs and health system”—could provide this equity lens.71 Whereas social responsibility within medicine aims to attain outcomes defined by health care organizations, social accountability aspires to define metrics and success with communities.
Policies that hold primary care accountable to society and monitor equity-related outcomes could be institutionalized if they are implemented across all sectors of health care—from medical education to clinical practices to administrations. An example in the medical education realm: while social responsibility may develop community medicine rotations to provide exposure to SDHs, social accountability requires the involvement of community organizations in the creation of the curriculum and measures the number of residents with sustained participation after residency. Summit participants identified the development of SDH interventions, hiring practices in professional organizations, and health equity research goals as targets for applying social accountability.
Discussion
The Starfield Summit renewed our commitment to Dr. Starfield's legacy, affirming the significance of primary care in health care systems, while emphasizing the specific and unique role for primary care in advancing health equity, which Dr. Starfield recognized as critical. To fulfill this role, we must progress from identifying existing inequities toward implementing feasible interventions to address them. Based on Summit speakers' presentations and participant discussions, we identified key actions encompassing the Summit's 4 domains, outlined in Table 4; these include implementing EHR-based tools that support SDH monitoring, refining these tools to enhance clinical decision making about SDHs, partnering with community organizations addressing health equity, equipping health care professional students with an equity mind-set, and applying a social accountability lens within our institutions.
Implications for Action Based on Themes Discussed at the 2017 Starfield Summit
Some of these goals are immediately actionable, but many others require a commitment to sustained and coordinated efforts among primary care clinicians, researchers, educators, and advocates, as well as policymakers and community organizations. Although the Summit showcased numerous primary care bright spots in achieving health equity, a paucity of research exists to guide how primary care can most effectively address SDHs on a wide scale, with innovations currently outpacing the evidence.72
One central premise of the Summit was that primary care can identify opportunities to drive some societal efforts to advance equity, and primary care can complement the work already being done by community organizations with the unique assets it may offer. Over time, clinical-community partnerships could offer bidirectional learning that encourages innovation in SDH interventions and brings the rigorous implementation research necessary to examine scalability across populations. With the national movement toward developing learning health systems73,74, centering clinical-community partnerships within those systems could promote an equity and social accountability lens that guides rapid development and translation of health equity evidence to clinical care, medical education, and communities.
Conclusion
Although much is known about what health inequities persist in the United States, coordinated efforts across sectors are necessary to intervene in them effectively. The time is now to build on Dr. Starfield's work, by embracing the significant role of primary care in addressing both medical and social ailments of our country, so that we can achieve health equity for all.
Acknowledgments
The authors gratefully acknowledge formatting assistance from Amanda Delzer Hill of the Department of Family Medicine at Oregon Health & Science University.
Notes
This article was externally peer reviewed.
Funding: none.
Conflict of interest: none declared.
To see this article online, please go to: http://jabfm.org/content/31/2/292.full.
- Received for publication July 1, 2017.
- Revision received September 29, 2017.
- Accepted for publication October 20, 2017.
