Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: And welcome back after our break. So we have with us Lisa Rosenbaum, Doctor. Rosenbaum. And I talked about it actually in this committee before. I have been listening intently to a podcast that she does to New Journal of Medicine and has devoted her entire season to primary care. And I've invited her in. We are getting ready to work on a bill that is coming over from the Senate around primary care and kind of using this week as education for our committee for things that we should be thinking about levers that might be pulled and more importantly, that we probably should not be pulling. So I thought it would be helpful to have you in and maybe you can just kind of talk to us about a little bit. I know that you've done a lot around sort of workforce and challenges, but just sort of in general, lessons learned and things that might benefit us. So we really appreciate you making time and space for us.

[Lisa Rosenbaum, MD (Guest Witness)]: Well, it's such an honor to get to be with you. So I had a few thoughts about how to best do this. Can definitely talk about how all this started. I also pulled up I know some of you have listened to the podcast, but I also wrote five essays about this. And I was thinking about reading the beginning of the first essay and the fifth essay. Maybe if that would just give you a sense of some of the thinking that I don't know that got captured on the podcast. But I can also just tell you, I'll just tell you anyway, how this all began, which is that a friend of my uncle's actually relatively, like, wealthy, well resourced person asked me to help him find a primary care doctor in Boston. And I tried to help him and very quickly heard, I'd never verified that this was absolutely true, but that no one could get a primary care doctor for a year. And that some people weren't even putting people on wait lists. And so I told him that if you wanna get a primary care doctor, you have to pay for concierge. And so my intent actually was to just write about concierge medicine. I didn't set out to write about primary care. And what became quickly obvious to me was that concierge medicine was a symptom of this much deeper problem in primary care in terms of the experience of physicians and also of patients who really value something that traditional primary care was not always giving them. And so I think I took a little bit of a different approach to concierge medicine in terms of I didn't, I wasn't highly critical of it. I recognized obviously that there are huge questions around equity, but I was far more interested in what it was that physicians felt they were able to do that they couldn't do before and what the patients were willing to pay for. Because a singular theme in this whole opus has been how drastically we've undervalued primary care. And so I was very taken by not just like that people were willing to pay for relationships, but the real quarterbacking role that concierge physicians were able to play for their patients when they had the resources to do that. And I actually told a story that it's in the second essay about concierge medicine. Sort of the first time it dawned on me that this wasn't just about wealthy patients who were paying for sleeping pills, because that's how I had kind of thought about concierge medicine. So I'm a cardiologist. I'm not a primary care doctor, but I was taking care of. I only take care of patients in the hospital, so they tend to be sicker and I was taking care of a young patient. I don't know, over five years ago before the pandemic who came in with cardiac tamponade. And you know these are situations, especially when it's a young person with new pericardial effusion and tamponade They give me a lot of anxiety because we always have to worry about cancer and the drain had come out and the patient was stable hemodynamically and wanted to go home. And I was really worried about who would catch the patient on the other side, especially because cytology was pending in all these labs and I didn't know what had driven this. And Saturday morning, know, it's obviously it's much harder on a weekend to get things coordinated for people. I get this page and there's a doctor on the other side who's like, yeah, like he seemed to know more than I did about what was going on, which was crazy. And he was like, oh yeah, no, he like this patient is in my practice. I'll take care of everything. And I was like, what? Like what is this? Like how have I not sort of noticed this before? And also why can't everyone have this? And that sort of like is when concierge medicine entered my own sort of realm of possibility, but also it became, as I wrote this series, something that helped me understand what people want from traditional primary care that had become so much harder to deliver. So with that sort of preamble, I am happy to read to you, but if that sounds boring, I'm also happy to just talk and answer questions. I just don't have a great sense of how I can best help you.

[Alyssa Black (Chair)]: Well, about reading to us a little bit? You want

[Lisa Rosenbaum, MD (Guest Witness)]: me to read? Okay. Yeah. Okay, if you get bored.

[Alyssa Black (Chair)]: And then if we have questions, do you mind if we just jump in?

[Lisa Rosenbaum, MD (Guest Witness)]: No, I'd love that actually. It makes me feel much better. Okay, so this is the beginning. This is the first essay I wrote. It's called, Is a Long Summering Crisis Boiling Over, US Primary Care Today. After her internal medicine residency, Doctor. H joined a Midwestern practice inheriting a primary care patient panel from a retiring endocrinologist. At first, the work was hard for the right reasons. She diagnosed and treated a wide range of diseases, built long term relationships with patients and families, and until the rise of hospitalists, cared for them in the hospital as well. Becoming the consummate internist was exactly what she'd signed up for. Lifelong learning and getting to help people, she recalled. It was the best job in the world. She didn't recognize that this traditional generalist role was in peril until about fifteen years later when she joined a multi specialty practice owned by a nonprofit foundation. The work was initially fulfilling, but as the insults to primary care accumulated, shorter visits, unmanageable inboxes, a staff exodus during the COVID pandemic, Doctor. H gradually lost her capacity to function as her patient's doctor. Like many primary care physicians, she adjusted to the squeeze by working more. Without staff support, she roomed patients, took their vitals, and scheduled tests and follow-up. When leadership threatened to cut physicians' vacation days if their documentation was late, she started spending hours at night charting despite caring for a young child and a chronically ill husband. But one change she couldn't work around was the lost capacity to see her patients when they were sick. Forbidden from double booking to accommodate them, she often didn't hear about patients who needed her until after a centralized triage system had diverted them to urgent care. A patient with recurrent herpes infections, for instance, called seeking a refill of valt cyclobir. The staff, following an algorithm, told her she required a clinic visit since she hadn't seen Doctor. H for a year. With no appointments available, she was sent to urgent care where the clinician wouldn't prescribe the medication without a culture. Doctor. H eventually received the message and refilled the medication. But as similar situations often with much higher stakes recurred, she began wondering, what does it even mean to be someone's doctor if you can't be there for them when they need you? So that is how I started the first.

[Alyssa Black (Chair)]: I think I have a question right from the get go. How should we even define primary care?

[Lisa Rosenbaum, MD (Guest Witness)]: That's such a And good

[Alyssa Black (Chair)]: we talk about it so much, but do we even really know what we're talking about?

[Lisa Rosenbaum, MD (Guest Witness)]: Right, yeah, this was a thing that I spent a lot of time thinking about, so I'm so glad you asked. So the National Academy of Sciences and their reports, they have a definition that I can't recall offhand, but it's something about taking care of most problems over time, like being the first pass of a lot of things that the healthcare system is meant to address. I really bungled that, but it's something like that. But I think that one of the questions for you, for me, for all of us is as primary care is pushed into these sort of algorithmic silos, meaning we say that like AI is going to do a lot of it and physicians are likely to be replaced by advanced practice practitioners where what we're looking to primary care to do is essentially meet a bunch of metrics like blood pressure, hypertension, I'm sorry, hypertension, blood pressure, same, diabetes, cancer screenings. I think it's incumbent upon us to ask, is that really primary care? And I would say no, that is not what primary care is. It's certainly part of primary care. And if the primary care workforce is not responsible for these type of population health metrics, it's unclear who it would fall upon. But I think what I learned in reporting this area is primary care is about relationships. Like there is no primary care without a relationship. And when you have a relationship with a person, you are able to figure out what matters to them. And then you can structure all of your care around that. And so a lot of people, of course they want their diabetes and blood pressure controlled, but they might have impediments to doing that. They might not have access to healthy food. They might not be able to afford their medication. What primary care truly does is understand the social challenges, the familial challenges, the personalities that make us human and figure out how to meet people where they are. So that is not a great definition because it's too long winded. And I feel like it can only be captured really through stories, but that is what I think primary care actually is and should be.

[Alyssa Black (Chair)]: Leslie has a question and I loved your answer because it actually spoke to our last witness who testified and some of the things that they were talking about as far as things we've tried to measure. But go ahead, Leslie.

[Leslie Goldman (Member)]: Yeah, you, Doctor. Rosenbaum. I am a retired family nurse practitioner, so you understand that's my bias. And I worked for thirty five years in primary care. And I love your definition, except operationalizing it almost feels impossible. And that's where I get stuck. Because yes, I can have a relationship with someone today,

[Alyssa Black (Chair)]: but I'm not going to

[Leslie Goldman (Member)]: see them again for four months. And life goes on, and then not for another four So maybe over the course of a year, I'll see someone for two hours. And then the rest of the time, they're out in their world. So to put their responsibility on primary care for all the patient outcomes in so many arenas, And as we talked about earlier, we know that health care only affects twenty percent of someone's health. I think primary care needs to be beyond clinician, the doctor, the APP, whatever, and really seen as a more universal sort of approach. And I don't see anyone thinking about that.

[Lisa Rosenbaum, MD (Guest Witness)]: Well, I completely agree with you first of all, the burden of responsibility upon primary care to be responsible for these hosts of metrics that we think of as population health seems not only unfair given that the rest of us are doctors too, but also not what I think we should use to define primary care's worth. And so I think when you think about operationalizing primary care, like if I were in charge, if there were a primary care sort of federal agency, I would take all of that away. I would give every practice, I mean, is the other thing that was just like so eye opening for me in the reporting is that every community has different needs. And I really still believe that clinicians like you, you have an ability way more than someone like me or like somebody who's working at a very high policy level to know what your community needs. So the first thing I would do is get rid of all these imposed measures of success and say, how do we give people the tools in any given practice to meet a community's needs? Now, the thing that throws a wrench in that is that we've seen so much consolidation. So we see health systems who are hiring primary care doctors, stripping these clinicians of autonomy, and really sort of focusing on profit and throughput above all else. And we all know that it's more lucrative for these large health systems to have primary care clinicians refer to specialists or order a bunch of tasks because that generates revenue for the health system. So somewhere like the incentives have been so misaligned. And I think we've tried to address that through value based payment design. But I think as one of my sources told me like primary care is always practicing in the shadow of fee for service. Meaning even if you have like the primary care group in an ACO contract, you still have the incentives for fee for service that is sort of driving how the system treats the practice. So I don't know how to undo consolidation, but I think that the loss of independent practice that we have seen across medicine, but particularly in primary care has been decimating to primary care's capacity to sort of do what you said, which is to be able to build those relationships in a little bit more robust way. Honestly, seeing everybody four months, seeing someone, I think that is a reasonable standard to seek. I mean, it's not perfect, but every four months is better than never. And like a third of people in our country don't have a primary care clinician at all, you know? And so I think every four months with a more open agenda that is not imposed by these external ways to define how primary care should be valued would be a good start. And I think it's possible because I think that there is a lot of dogma that sort of gets has just gotten carried through on a policy level around value based payments being the panacea, but very little work to sort of ask, what would it take to help these practices be independent again? What would it look like to give them autonomy? Those are harder questions to answer, but I think we can at least begin asking them and realize that like a payment model is not the solution to primary care. It's so much deeper than that.

[Leslie Goldman (Member)]: What is the solution then?

[Lisa Rosenbaum, MD (Guest Witness)]: I think so I I it's funny because I just I'm wrapping up the the podcast season, and I just had to, like, put the final touches on the last episode this morning. And the whole opening is about how my job isn't to like tell everybody what the solutions are because everybody knows, but I will I will tell you what I perceive to be the fundamental solution, which is about a resource primary care. It gets 5% of healthcare dollars and is responsible for like 35% of outpatient visits. And of course that varies by state. But I don't think it's I don't think there's any path forward for primary care that does not address the resource shortage. And when you talked and asked me initially about feeling like you're bearing the burden yourself, you're not just talking about like why can't cardiologists manage blood pressure? That's part of it. But where is the case manager? How who's helping people get mental health services? Who's helping them with nutrition? When I talk about better resourcing primary care, that's what I mean. So I think I think that all roads lead to more money being directed at primary care. So I think the question for me in this reporting sort of was, okay, everybody knows what the solutions are. If you go back fifty years, people are saying there's a crisis in primary care and it needs more resources. So we've been saying this forever. So I felt like part of my job, just given like what I'm inherently drawn to is what are the barriers to implementing that solution? Why are we having such a hard time making those dollars available to primary care? And that opened up a whole can of cultural worms and some bureaucratic norms, but a lot of it is about values as a culture, as a society, as a profession. And I think a misunderstanding, a fundamental misunderstanding of what primary care can be. And the reason I opened as I did, and I didn't get to this part in the reading was because I'm a third generation physician. My grandfather was a rheumatologist, but at the time, he also functioned as a lot of people's primary care doctor and practiced rheumatology. And there was an archetype in medicine around being someone's doctor over time and sort of being the consummate internist for them. And I'm afraid is has become a vanishing breed, and I don't think it has to be. But in order to bring it back, a lot of things have to happen both within and outside the profession to value that type of work again. And I'm not talking about hospitalist medicine. I think what part of what we've seen is that a lot of people who come into internal medicine residencies, which is theoretically a pipeline for primary care, they get trained primarily in the hospital and the most natural next step is to become a hospitalist. As you know, what primary care does is so very different. But I think that model of being like the all knowing internist who cares for their patients and often their families, both inside and outside the hospital has been lost. And I don't see anything inherent to the nature of healthcare today that means that we can't resuscitate that genre of doctor.

[Alyssa Black (Chair)]: We actually just had in this morning the CEO of one of our critical access hospitals who also is a FQHC as well. I see the FQHC person over on the side donning her head. Additionally, they are beginning, well, they have received approval for sort of a rural family medicine residency. And because currently we only have the University of Vermont College of Medicine and residency program through our academic medical center. And I was thinking about this a lot actually when, you were discussing it on your podcast is that when you're training in sort of an inpatient environment that you have a tendency to end up practicing in that and then you become a hospitalist. And I'm wondering if you see investments in a more rural residency program as sort of maybe having more value to kind of create the consummate generalists that we're looking for if you see value in investing in that?

[Lisa Rosenbaum, MD (Guest Witness)]: I see tremendous value in investing in that. And short of giving practices the autonomy to figure out how they wanna use their resources to best serve a community, I think that investing in more rural family medicine programs might be the single best thing that we can do for primary care sustainability. I'll tell you, I mean, few stories. Some of you probably already know from listening to the podcast. So one of my interviewees is someone named Benjie Popoke, who's a fourth year at UT Southwestern. And he always knew he wanted to do primary care, but it was just based because he did it in a way rotation in a rural family medicine practice that he like really fell in love with family medicine and decided he wanted to practice rurally. He calls it like being a doctor with a capital D, but you know, he was with shadowing the physician or doing what third year medical students do, is which more than shadowing. And like they would do colonoscopies, they would do routine gynecological care. Was just the spectrum of practice was vast. And I think the other thing that really was captivating to Benjie was like the clear role that people like his preceptor played in the community. Just to walk around, that's why he kept calling it doctor with a capital d, with that aura of doctorness that I think can get lost when you're living in a big city, not just because you're walking around unrecognized, which is fine with a lot of people, but also because I think we've seen this massive erosion of physician authority, which is like part of a much broader challenge that we're not necessarily here to discuss. Although I will say that I think we talk about trust in extremely abstract terms, and we look to institutions to restore trust. And my profound belief is that a lot of the loss of trust that we're witnessing is happening because so many people don't have a primary care doctor. And I think those who do usually trust them. And I think that relationship void has spilled out into what we're seeing with all these challenges around vaccines and misinformation. Those are the things we talk about when we talk about trust, but to me the root ill is the relational void. So yes, I think that we should fund more rural family medicine programs. I think somebody is coming on my last episode that you haven't heard yet, who started one himself in Port Angeles, Washington, and I'm happy to put you in touch with him because I think it was one of the most meaningful things. He's had an incredible career, but it was it's in listening to him describe, like, starting that program where you just you hear, like how enriching it's been. And also, one thing he told me that was very striking was that a lot of they ended up starting an FQHC as well. And one of the draws for a lot of the physicians on faculty is that they get to train residents. Like it's enriching in both directions. And it wasn't easy. I mean, there are you have to get the money. You have to it takes years to do. You have to develop the curricula. But he did it and he loved it and it's been meaningful. And I think I'll tell you one other thing that I heard from Rachel Criswell, who's a family medicine physician in Maine. I think she told me at some point like somebody from the community had seen her as a doctor and expressed like some interest in becoming a doctor, but like didn't even realize that like people from this community could become doctors. So there's this sort of holding on to our own within communities, having role models to inspire younger generations who are more likely of course to wanna live there if they grew up there. So yes, I think it's a virtuous cycle to fund more family medicine rural programs.

[Alyssa Black (Chair)]: Well, that makes one decision easier. Thank you. Did you want to go ahead with Oh. If you had any other things you wanted to read? Sure. Because of reading and formulating questions.

[Lisa Rosenbaum, MD (Guest Witness)]: Okay, I'll read while you think. And so this is the last essay. So the second essay, the first essay sort of introduced the challenge. The second essay was all about concierge medicine. The third was about sort of whether we have taken all the metrics and the value based payment and sort of the algorithmic nature of it all too far. And also whether primary care should be so focused on prevention when we are not even meeting the needs of those who are sick. So that was the third. The fourth was about our cultural values. It was about the RUC, the group that determines payments under the RBU based system and sort of the genesis of the RUC and the values within the profession that have sort of codified some of the undervaluing of primary care that we see. And then basically like the last essay is this attempt to question our values, our professional norms. And so it's called immeasurable excellence, what happens to medicine without the good doctor. When Adrian Cibeti was pursuing a PhD in economics, her grandmother's primary care physician retired. Though her grandmother filled the care gaps with increased specialist visits, her distress suggested to Sabeti that the benefits of their contribution added up to less than the overarching benefit of a long standing relationship with a PCP. Sabeti wondered, could this loss be quantified? Her dissertation published in the Journal of Public Economics suggests that it can. After PCP loss, patients who have relationships with specialists see them more often relying on them to meet primary care needs. Nevertheless, among patients who have lost their PCP, mortality, emergency department visits, and hospitalizations increase the year following the PCPs exit, probably contributing to about $46,000 in additional Medicare spending for each exiting PCP. Furthermore, the frequency of adverse events in patients who have lost their PCP increases in proportion to the relationship's duration, suggesting that the relationship itself conferred health benefits. In what she calls the no new friends model of PCP loss, says Betty likens the phenomenon to the experience of someone in her seventies living in an urban area with a steady stable of friends, each of whom shares with her one common activity. Let's say I have a show friend, a dinner friend, and a walking friend, she said. If the show friend moves away, you'll probably spend more time with the other friends and see fewer shows. But the average person probably won't make a new show friend. Similarly, after PCPs exit, only twenty three percent of patients form a new relationship with a PCP. Though some observers might blame the negative outcomes on poor access to primary care rather than the relationship loss itself, adverse event rates were actually higher in more PCP dense locales, suggesting that poor access wasn't solely responsible. So Betty nevertheless urges caution in interpreting the findings. This only tells you what happens when people lose an existing relationship, she said. Indeed, the data could raise a diametrically opposed question. If losing a relationship creates risk, why have one to begin with? That this question in another context could trigger years of psychoanalysis, hints at one of modern medicine's tendencies, attaching disproportionate meaning to things that we can count. Sure, Sabeti's data don't eliminate the possibility that people with a nonexistent or short term relationship with the PCP will fare better because they'll face fewer harms if the PCP leaves. But can't some things in life like a relationship with a trusted physician be worth sustaining even if the benefits aren't measurable? If everyone believes such relationship matter however, there would be less tolerance for the constraints placed on PCPs. Because medicine has imbued the measurable with so much power, I loved Sabeti's study for assigning a value to this connection. But I wondered how much has primary care suffered because the worth of the unquantifiable goes unrecognized? Okay, can I give you, I have a little cold and I need to grab a tissue? Can I give you a thirty second break to generate questions and I'll be right back? Is that okay? Okay. Thank you.

[Leslie Goldman (Member)]: Well, so she just said the work of primary care is unquantifiable. How do you deal with that? I mean, I'm thinking about it in terms of this bill. How do we resource something that's unquantifiable?

[Daisy Berbeco (Ranking Member)]: It's in here.

[Alyssa Black (Chair)]: That doesn't equate to a dollar or a percentage. What you should spend. Do we

[Leslie Goldman (Member)]: need figures?

[Alyssa Black (Chair)]: Need figures on Yeah, need

[Leslie Goldman (Member)]: really think about that. I mean, I haven't seen the bill yet because it hasn't come over and I have, maybe it never will, who knows? I'm not sure what time it takes to do that. Yeah, I think we'll be here by the end of the week. It's on January.

[Karen Lueders (Legislative Counsel)]: Karen Lueders, Consul, you're talking about S197? Yes. Yes, I believe today is reconsideration day, holdover day in the Senate and that should get messaged tomorrow. Although it may not be messaged until after you're on the floor, in which case you may not see it until next. So they have different rules, I don't get that level of rules.

[Leslie Goldman (Member)]: Okay.

[Alyssa Black (Chair)]: Oh, you're our third witness of the day. And I am So I'm like piecing together a couple of things that we heard through the day. So first of all, there was a slide from our first witness and unfortunately he's not here anymore and he's wonderful, but I didn't ask about it at the time. Says chronic disease is the number one cause of death in Vermont. And I'm thinking to myself, isn't that a good thing?

[Lisa Rosenbaum, MD (Guest Witness)]: As opposed to acute illness?

[Alyssa Black (Chair)]: As opposed to an acute illness or a traumatic death. So wouldn't chronic disease be maybe I'm misinterpreting the slide and I should have asked. The other thing, and I'm thinking about sort of like in this notion of the longitudinal relationship with a provider and how you quantify it. We were talking about quality measures earlier and one of the quality measures that just kept coming up was have you screened for depression or mental health and how great it was that more people were screening for it. And I had actually asked the question, who cares if you screen for it if you have no resources to refer somebody to help them. But also I'm thinking about it in terms of my own personal self. I am lucky enough that I have a primary care provider who has been my primary care provider for at least ten years, who took over practice of my previous one that I had had for twenty years before that. And I recently went to my annual physical and the first thing of course is they screen you for depression. And my primary care is being measured on that, but she doesn't need to do that because I have trusted her and she knows me. And what difference does it make if I fill out that stupid GAD whatever? Because I have a trusted relationship with her, I've been able to, you know, over the years, talk about things like that. And she doesn't need to screen me because she knows me. And I'm wondering we just dumbed down the entire specialty, which in a way maybe is interfering with developing that trusted relationship?

[Lisa Rosenbaum, MD (Guest Witness)]: I think yes. So I'm going start with your second question. I had an experience, I think it was like ten years ago, I had to get an endoscopy and I was sitting there like with the IV in and no, there was like a nurse doing my IV and then there was a medical assistant who was had her back to me on the computer and she's going through her checklist and she goes, do you feel safe at home? I was like I was like, well, yeah, but if I didn't I I think I actually said to her, I was like, does anyone say no in this setting? Like, are you really like, do you really think this is the way to get at domestic violence? And I think something very similar is happening with the depression screening, which is it's become it's something that is very personal, very painful. And when you turn it into a checkbox task that's often not even undertaken by the physician themselves, it's something a lot of people have shame around. You just completely lose the thread of people's willingness and ability to talk about it. So I agree with you, like, in terms of, you know, if you if you trusted her and you were feeling depressed, she's someone you would bring it up to. And I think that for many people, the screening forms like reduce what they're feeling to something that feels very technocratic. And I just don't think I think that a lot of those things that we do is indeed a dumbing down and that was a phrase multiple people used to explain to me what some of these screenings have done to primary care. So that raises other questions like it. Oh, I mean the other part of your question besides the big first question is and I heard this from from physicians, like, why am I asking somebody who's depressed so I can throw up my hands and say, well, there's nobody available to see you for, like, six months to a year because we don't have the mental health resources. That's part of the problem too. I don't think that that alone should keep us from figuring out if our patients are struggling with mental illness. I think there are certainly primary care doctors who have become very facile in treating mental illness, at least pharmacologically because of this. And then, you know, the whole challenge around mental health. I mean, I have some optimism that, like, more virtual health resources. I I'm not going to bring up AI in this context yet because I have no idea, like, really what that will amount to. But I think you're the sort of the locus of your question, like, is this screening done in this, like, perfunctory way that has dumbed down like the practice of primary care itself? I would say yes. Do you want me to address your first question or did you have something you wanted to say?

[Alyssa Black (Chair)]: Let me go on to, because I know I've got Daisy has a question and Leslie has a question.

[Daisy Berbeco (Ranking Member)]: I'm really maybe just thinking out loud, but it's around quality in care. When we're talking about screenings, for example, I think there's great value in having metrics, whether it's about a patient or whether it's about a diagnosis code across a population and looking at are we moving the needle on that diagnosis with the clinical approaches we're taking, for example. We need that data in order to improve our approaches. I think my question is, are we investing enough in providers so that they can capture that data in a way that is authentic and leverages the skills that they bring to the job. My providers give me these questionnaires and it's not like, okay, they're not checking the box. They are asking the questions for sure. Do But you know what I'm saying? I feel like there's a balance of investing in quality of data, but also quality of supporting the clinicians and how they gather that data in a way that is also qualitative?

[Lisa Rosenbaum, MD (Guest Witness)]: Yeah, so this is something I could spend my life talking about. Before I wrote the primary care series, I wrote a series about training. And then before that, I wrote about quality. So I wrote three essays about quality. And I fall into a camp of we all know quality when we see it, and it doesn't always lend itself to measurement. And I think there have been a lot of unintended consequences of trying to measure it. And the brunt of those consequences have fallen on primary care, I would say in two ways. One is the time to meet the metrics, but probably more importantly, the resources that are needed to extract the requisite data to get paid. So when you ask, how do we support primary care in getting good data? I think right now we've taken sort of a myopic approach, which is they have to pay for the EHRs or whatever it is to get the data they need to show that they've met the metrics to get paid under these value based contracts by various payers. And so I don't I I you know, I haven't reviewed the literature since 2022 or 2023, but was pretty clear what became pretty clear to me at that juncture was that no quality measures seem to have actually improved quality except maybe the checklist around central lines in inpatient setting. And I could be wrong because it's been a while since I've looked at those data.

[Alyssa Black (Chair)]: That's correct too. The line

[Leslie Goldman (Member)]: that keeps talking about.

[Lisa Rosenbaum, MD (Guest Witness)]: But I think the philosophical point remains. I think one of the most interesting things to me, and I guess the essay, the fifth essay that I started reading really gets at this. I wrote about a colleague of mine at my former institution who used to sign out his his patients to me when he traveled. And it would fill me with dread because he was such an exceptional doctor, and I so wanted his approval. I so wanted to do whatever he thought was the best for his patients. And so it created a lot of anxiety for me. And then I left the institution so I never have to cover him anymore, And I found myself longing for it. And I think I longed for it because in the process, anytime I get a call from one of his patients, I would go through his notes. I would go through his thinking. And that process was extremely educational for me. I was learning all the time. I was looking at what I considered to be excellence and quality and dissecting what it was he did to create that excellence. And it was a qualitative process. It was not a quantitative process. And I think there's a huge, like, untapped sociology of medicine whereby I think a lot of people like, when you call somebody, when you call a friend because somebody you love is sick and you say, who should they see for their brain tumor? Who should they see for their leg pain? Who should they see for their hyperlipidemia? What you're really saying is who is good. And we all you wouldn't do that if you didn't recognize that we all carry the knowledge of who around us is good. And I've never been able to correlate that very intrinsic sense of goodness about those around us with the way we've decided to measure what makes someone good. So I think there's probably a middle ground where you say, like, yes, quality matters, and there are things that we should be measuring, and we should think of ways for people to have access to those data so that they can improve. But I think it's gone too far and it's like a huge industry that is extremely costly for our health system at large. And I'm not at all convinced that it's actually improved quality.

[Leslie Goldman (Member)]: Leslie. Thank you again. While you were on your break, what came to mind, and I mentioned it to the room, was how and you had said something about how primary care is unquantifiable. So the question that came up was, how do you resource something that's unquantifiable? Because what I'm also hearing you say, and as we deal with this bill that's going to come through, we need more resource. We'll need an argument to do that. But if you can't quantify it so it just seems like this really dark hole.

[Lisa Rosenbaum, MD (Guest Witness)]: Well, I mean, that's sort of a philosophical question. Like, can we accept as a society that there are things that have a moral valence that we ought to be doing that might not be quantifiable. And I look at primary care as a social good that everyone deserves to have a primary care doctor. And I mean, I guess when we think about education, for instance, we try to quantify it by test scores and things like that. But I'm also not convinced from that literature that that's actually helped in any way. I think social media is in a sense facing a question like this insofar as there's, like, a group of people who try to prove that it's, like, bad for adolescents based on data that's correlational rather than causal. And so the whole debate gets mired in these scientific details about correlation versus causation. And when I look at that debate, I think like, how much data do we need to, like, be able to say what we see with our own eyes, which is that this is bad for teens to spend all their time comparing themselves to others on social media. And so I think I feel similarly about primary care, which is that the moral valence of a social good does not need to be arbitrated by metrics. I think it's a very particular sort of American technocratic approach that feels like very of the moment in 2026 that somehow, like, we can only better resource it if we can prove that its value exists through either saving money, which is ridiculous because we don't wanna ask other specialties to save money, or because it reaches a set of outcomes. And I guess I will say one more thing about this, which is that I what what I witnessed during the pandemic, and I can say it sort of radicalized me in a way it didn't rattle it radicalize me and making me like maha. But it radicalized me in a way that forced me to recognize that what we think of in health as like the right outcome is not necessarily what matters to other people. And you know that people would rather risk getting COVID than giving up their business, that they would rather risk getting COVID and get to sit by their wife as she died in a hospital in a time when we had a no visitor policy. And what I'm trying to say is there are values that humans carry around their health that often do not fit in these like tidy frameworks of is your blood pressure under 140 over 90 or whatever it is. Is your A1c less than seven? And so if we can recognize that what's meaningful to people around their health may not be measurable, it becomes easier to understand why primary care as a longitudinal relationship based way of getting healthcare might also have value.

[Leslie Goldman (Member)]: Thank you. I'd like to put that in the bill. Okay, you got that?

[Alyssa Black (Chair)]: Well, I've actually said for years that if I had total and complete control over everything, every primary care provider would provide direct primary care and everybody would have a concierge physician and then the state would pay for it. That's my dream.

[Lisa Rosenbaum, MD (Guest Witness)]: I mean, I have It's my a reasonable dream. Like there are people, I mean, we did an episode on concierge and direct primary care, and I ended up focusing more on direct primary care because I sort of neglected it in the writing. But, you know, direct primary care costs a lot less than concierge and Medicaid could theoretically think about direct primary like covering everyone for a direct primary care doctor. I I mean, I think there are proposals out there that would use primary care resources toward funding that where you have, like, all these people with their doctor's cell phone and ability to get in when they're sick. Like, can you imagine? So I think I think there are ways with a little bit of ingenuity and willingness to sort of recognize the constraints that we've been operating under.

[Alyssa Black (Chair)]: Thank you. I didn't get a chance to ask you, and we do have to get going. But maybe if you could send us a possible resource. We didn't talk at all about the use of or the future of AI in primary care. And I feel like it's pertinent because of the Rural Health Transformation Program. As part of our grant, we did have, you know, we do have the ability to implement some AI tools into community providers and, you know, invest in that sort of infrastructure, IT infrastructure. But I'm thinking about how we want to make sure that we're investing in the right things and not the wrong things. So if you might, because I know that you've done a lot of episodes on this.

[Lisa Rosenbaum, MD (Guest Witness)]: Two. I've done two and I'll send them both.

[Alyssa Black (Chair)]: Yeah. And also maybe resources from someone who is sort of has expertise in the area and maybe we can reach out to them. That would be great.

[Lisa Rosenbaum, MD (Guest Witness)]: Okay, let me I have to think. I have to think, but I will think.

[Alyssa Black (Chair)]: All right.

[Lisa Rosenbaum, MD (Guest Witness)]: Yes, I will do that. Should I send them to you directly or?

[Alyssa Black (Chair)]: I can send them to the committee assistant. Tasha sits over in our corner. Very, very important person. The most important person in this room is actually Tasha.

[Lisa Rosenbaum, MD (Guest Witness)]: Okay.

[Alyssa Black (Chair)]: Thank you so much. It has been such a pleasure. Thank you. I really appreciate you investing your time and just talking to us and giving us things to think about. And I can't wait for the last episode.

[Lisa Rosenbaum, MD (Guest Witness)]: Thank Thank you so much for listening. And it's such an honor to get to talk to you. So I will be in touch. Thanks. Thank you. Okay. Bye.

[Leslie Goldman (Member)]: Thank you.

[Alyssa Black (Chair)]: Alright. We are done. We're done for the day, obviously. So we are back here tomorrow afternoon, hopefully.