The primary care challenge (and solution?)

There is no doubt of the importance of primary care in healthcare. As the graph above shows, primary care is the largest platform of healthcare delivery in the country. This fact was not lost on those who were instrumental in thinking through health reform (PPACA), and how to address the triple aim (care, quality and cost). Primary care as seen through the lens of the patient-centered medical home was throughout the bill.

When one considers the critical functions of primary care, there again is no doubt how healthcare needs a robust and high functioning primary care system. As the defined by the IOM:

“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Some of the secret ingredients of primary care are found in comprehensiveness and continuity. These two elements allow for the primary care systems to address all aspects of one’s health, over time, through a relationship established with the provider or team. However, there still appears to be a dominant thought amongst the public that more services means better outcomes and that more specialty care means better care. This mentality does not lead to better health nor does it help bend the cost curve.

No one can articulate the differences between specialty care and primary care better than the late Dr. Barbara Starfield:

“The desire of Americans for more and more health services seems to be based on the belief that specialized care means better care. But inappropriate care can be harmful. Specialists are more likely to do tests because they have been trained in settings where people have a high likelihood of disease. The probability that a positive result of a test is accurate differs according to where the test is done: if in the community, the probability is one in 1,000; if in a primary-care practice, one in 50; and if done in a specialist practice, one in three. If people are referred too early to specialist care or seek it on their own, they are more likely to suffer harm than they are to benefit from the cascade of tests and procedures that are set in motion from just one false-positive test result. For example, prospective joggers who (either by choice or by following a recommendation) have a cardiac workup before embarking on their jogging program have higher rates of death than those who simply jog. False-positive tests lead to more tests and more treatments, and each of these runs the risk of harm, even death.”

While the healthcare system we all want needs to revolve around the patient and be as patient-centered as possible, there needs to be some education to the public on the differences in healthcare delivery and the importance of primary care.

There also needs to be a higher value placed on primary care. One cannot underestimate the value of continuity in healthcare, and this is especially true in primary care. Yet we have fewer and fewer primary care physicians entering the healthcare workforce, which will ultimately affect quality and the cost of medical care.

And while innovation in primary care remains, we have a challenge. We, the public, must begin to recognize that there is an answer to the healthcare problem right in front of our eyes – primary care – and the problem is not how to create it, but rather how to build it up and sustain it.

So how can we “fix” healthcare and enhance primary care? Since it is well documented that major changes in healthcare are often stuck in the muck and mire of politics, it seems as if the simplest solution is to organize our healthcare delivery around primary care and increase (or guarantee) access for everyone.

Again, Dr. Starfield:

“But if primary care is to improve significantly, the health-insurance system must also be reformed. The principal benefit of health insurance in the United States is facilitating access to primary care. Socially deprived populations that do not have health insurance are less likely to have a source of primary care and thus have less access to the entire health-care system. Every other industrialized country in the world has solved this problem. Not all have adopted government health insurance, but all have recognized that the health-insurance program must be either run or regulated by a publicly accountable body. Health insurance should be designed to include all non-discretionary health services for everyone, at the same price for everyone. Universal insurance is more efficient and effective when overseen by the government, at least partly because high standards for quality of care are more easily set and enforced. It is possible that a reasonable compromise, involving more accountability of private insurance, might be a transitional strategy.”

Enhancing primary care and making the largest platform of healthcare delivery more viable should be a major emphasis for any and all health reform efforts. Regardless of your politics and beliefs on how healthcare should be paid for, there is no denying how we all need a robust and high functioning primary care system.

As we continue to move towards change in healthcare, let us consider what is working, what is not working and what we can all do together to demand more of our system.

So the ultimate question is – do you have a primary care provider?

In some ways, this question should be the most important vital sign ever taken.

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

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