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Jan 2020

The Primary Care Dilemma!

The practice of primary care has probably been around since Hippocrates. However, defining it and giving it an identity only dates back to the 1960s when the term was first formally introduced.  How it is defined in any given context is sometimes based on who is giving the care.  For example the definition may take into account a specific type of clinician such as a specialist in family medicine or an OB/GYN; which activities are being conducted, for example, addressing common illnesses and disabilities; where the healthcare service is being provided, for example an ambulatory setting versus inpatient care.

The 1978 IOM definition includes care that is accessible, comprehensive, coordinated, continuous and accountable. Other definitions include  care that is characterized by first contact, longitudinality, accessibility and comprehensiveness; or even as a strategy for organizing and managing the health care delivery system itself, for example community-oriented primary care.

Unfortunately, having so many ways to understand and define primary care usually invites a lack of clarity and agreement as to what exactly this important function is.  One of the more recent, comprehensive and workable definitions is the one adopted by the IOM Committee on the Future of Primary Care, which defines it as “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.”   (Note: the IOM is now known as the National Academies of Sciences, Engineering, and Medicine).

With this view, primary care is intended to meet the ongoing needs of patients throughout their lives and in a variety of care settings.  It includes such activities as prevention, education, screening, diagnosis and referrals to specialists and other parts of the healthcare system when appropriate and required.  In this latter activity, the primary care clinician also serves as their patient’s advocate with the larger healthcare system.  The primary care physician is usually, although not always, a patient’s first “point of contact” with the healthcare system.  Some have even referred to them as the gateways to the healthcare system.

Having this set of definitions provide a common language for all members of the healthcare community, which is critical for helping to ensure quality of care.  It also is useful to show how providers can better enhance the benefits of primary care in their communities as well as address the challenges of accessibility and use it currently faces.

The Benefits of Primary Care

Numerous studies done both in the United States and in other countries all clearly indicate a wide range of population health and economic/financial benefits of primary care.  These include:

  • Saving time and money – Familiarity with a patient, and often his or her family as well, helps the primary care physician better customize and personalize care which can greatly reduce costs. In fact, one study suggested that people have a primary care provider save about 33 percent in healthcare costs over those who only see specialists.
  • Reduction of more expensive care options – Patients with a primary care physician have less of a need to visit the ER or urgent care for routine healthcare needs. One study suggested that almost 60 percent of patients who go to the ER probably could have been helped in a less expensive setting (a primary care clinic, for example, can provide savings of well over 300 percent over an ER). Early use of primary health can also reduce the need for more expensive specialists down the road.
  • Lower risk of premature death – U.S. adults who have a primary care physician have 19 percent lower odds of premature death than those who only see specialists for their care.
  • Reduction in healthcare spend – One estimate is that if everyone saw a primary care physician first, the US healthcare system would save some $67 billion a year. Another study indicated that every $1 increase in primary care spending results in around $13 in overall savings.

From a population health perspective, primary care has the benefit of increasing access to health services for disadvantaged groups.  It also tends to have better success at preventive interventions as evidenced by research that US states with higher ratios of primary care physicians to population have lower smoking rates, less obesity and even higher compliance with seat belt use.  It is even associated with an earlier detection of breast cancer, colon cancer and cervical cancer.  In addition, primary care has a demonstrable, positive impact on managing health issues before they become serious enough to require inpatient or emergency treatment.

The Challenges Facing Primary Care

The two greatest challenges facing primary care today are ongoing declines in the number of newly minted physicians embracing and specializing in this practice as well as a lack of patient interest and utilization of this type of care.

There are only about 210,000 physicians in the U.S practicing primary care for a population of over 325 million.  Unfortunately, only about 25 percent of the 18,000 U.S. medical school graduates go into primary care.  This has resulted in the U.S. having more specialists than it needs and fewer primary care physicians than it needs to meet the demand of a growing and aging population.

Looking at the latter, a recent study by the Harvard Medical School researchers at Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center shows that fewer Americans have primary care than ever before. This situation has been developing for some time.  The study also found a marked decrease in primary care among younger Americans.

And, while some researchers had predicted that the implementation of the Affordable Care Act (ACA) would have stemmed the decrease in primary care, post-implementation data have shown that it made little if any difference.  In fact, the largest decreases in primary care physician contact were seen among the elderly and those reporting poor health.  Given that the elderly utilize a disproportionate of healthcare spend, and those with poor overall health may tend more to use the ER for primary care, this continued decline in utilization does not bode well for providers nor for the communities they serve.

What Providers Can Do

There are several things that providers can do now to address these interconnected challenges.  These include:

  • Identifying ways – new and creative ways – to make primary care more convenient and more attractive to patients, and especially millennials and younger adults, by better implementing technology, offering flexible hours, and “going where the patients are” (additional suggestions can be found in this SAC blog on millennials and primary care).
  • Working with medical schools and the larger community to create incentives for recent graduates to enter primary care rather than automatically going into specialties
  • Working with healthcare provider associations to lobby for more federal support for primary care training and especially in rural areas where accessibility may be very limited
  • Establishing stand-alone primary clients either on-site or in the community that includes multilingual practitioners and staff (research shows that English not being a patient’s primary language reduces primary care utilization)
  • Considering a team-focused approach to offering primary care that includes nurse practitioners and other trained healthcare staff to increase capacity

It is undeniable that the continued decline in access to, and utilization of this traditional underpinning of the healthcare system poses a significant risk to the financial operations of providers across the country and a population health risk to the communities they serve.

Both access and utilization need to be addressed simultaneously if this risk is to be adequately addressed and mitigated.  On the one hand, increasing demand for primary care, especially among millennials and younger adults, without having the capacity to meet this demand would only address half of the challenge.  In the same way, increasing primary care capacity at the local community level without encouraging and making it convenient for people to take advantage of it also only fixes half the problem.  With an either-or approach, there would be no net increase in the number of people benefiting from primary care and no net decrease in the corresponding population health risk.


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