Promoting Primary Care
Primary Care as a High Value Proposition
O
ver the past 10-15 years there has been increased emphasis placed on “value” in health care.1 Yet, the meaning of what constitutes value varies; patients, providers, payers and policy makers have different ideas of what aspect of health care has more value and how these needs are to be computed.2 Despite this inherent challenge, there is a consensus emerging that a value-based model, as opposed to a volume-based one, will provide normative guidelines for better patient care. One of the essential questions then is: What value does primary care contribute to health care? This question should look at the essential tenets of primary care as a way to understand the value proposition — that of first contact with the patient, continuity with individual patients, comprehensiveness in care and coordination of care with other disciplines.3 The context and the community in which care is delivered are also pertinent in the delivery of primary care. Let us then look at “value” from different lenses. The main thrust of “Value Based Purchasing” is about holding providers, or health systems, accountable for both cost and quality of the health care delivered. What about the value of primary care in this? Do the transactional metrics favor primary care? Cost of Care — Low Value Care (LVC), is a metric that looks at unnecessary expenditure due to tests and other medical procedures performed that do not By Shailey Prasad, MD, MPH
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March/April 2020
improve quality of care. A recent study showed that Family Medicine physicians have, on average, $1.03 lower LVC spending. This was higher in the Midwest at $2.80, possibly due to increased primary care attributes in the Midwest.4 This shows that Family Medicine physicians tend to use less “low-value” or wasteful tests and procedures. Having a primary care physician increases preventive care and lowers hospitalization rates. This has shown to decrease total healthcare costs in areas with higher ratios of primary care physicians to population.3 This is also shown to be true among elderly living in metropolitan areas in the US.5 Medicare claims data analysis also shows a linear decrease in Medicare spending with an increase in the supply of primary care physicians, as well as better quality of care (concerning the treatment of six common medical conditions).6 Relationship with a primary care physician — In general, patients prefer relational value from interactions with the healthcare system rather than the transactional value that payers look at.7 The cornerstone of this is patient satisfaction.
Multiple studies have shown that continuity of care is the best predictor of this,8 and has strong correlation to improved chronic disease management, decreased emergency department use and improved quality of care.9 Adults in the US who reported having a primary care physician rather than a specialist, after controlling for differences in health status, smoking status, health insurance status, reported diagnosis and demographic characteristics, had lower five-year mortality rates. In other words, patients identifying with a primary care physician for their usual source of care are healthier, regardless of demographic characteristics and initial health status.10 Paul Batalden, healthcare quality thought leader, emphasizes the need to “co-produce” quality between the patient and the provider,11 and a requirement for this would be a trusted relationship between a patient and a primary care provider. Health Equity — Primary care physicians, particularly Family Medicine physicians, provide a disproportionate share of medical care for medically underserved (poverty, disadvantaged minority, uninsured) populations in the US.12 In the US, income inequality significantly increases all-cause mortality, heart disease mortality and cancer mortality. However this effect is considerably decreased when the number of primary care physicians is high.13 The impact on decreasing all-cause mortality is four times greater in the African American population than in the white majority population when there is greater supply of primary care physicians, indicating that primary care presence has a direct impact in decreasing racial disparities.14
MetroDoctors
The Journal of the Twin Cities Medical Society
