5 minute read
promoting prim ary care
Primary Care as a High Value Proposition
Over 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?
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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
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
Population level impact—Multiple studies have shown that the stronger the primary care orientation (measured by the comprehensiveness of services provided by, and multiple family members cared for, by a primary care provider) the lower the rates were of all-cause mortality, all-cause premature mortality, and cause-specific premature mortality from pulmonary diseases, and cardiovascular disease. This was seen in 18 developed countries, including the US. 15 While the US is generally considered low in primary care orientation, increasing the primary care score by 25% in the US is projected to reduce premature deaths from respiratory illnesses by about 6.5% and reduction in premature cardiovascular mortality could be as high as 15%. 12 The typical image of a primary care physician is that of a Marcus Welby. The tenets that made the fictional Dr. Welby successful: broad-spectrum practice, longitudinal continuity with the population that he served and inspiring confidence in the work that he did, is not a myth. Today’s primary care physician is all that and satisfies various aspects of “value” in the healthcare delivery. We need to continue to nurture and grow more to improve the efficacy of our healthcare system. The US is far behind in the supply of primary care physicians. There is a projected shortage of around 35,000 primary care providers in the US by 2025. 16 This is particularly important as the supply of primary care physicians, particularly Family Physicians, is shown to decrease all cause mortality. 10 An increase of one primary care physician per 100,000 population has been projected to decrease as many as 127,617 deaths per year in the US. 10 The University of Minnesota (UMN) consistently ranks among the top three in sending medical students to Family Medicine and other primary care fields. The Minnesota Medical School is the one of two medical schools in the country ranked in the top quartile of NIH research and overall social mission score (measured by the percentage of graduates practicing primary care, work in underserved areas, and are underrepresented minorities). 17 The Department of Family Medicine and Community Health at the UMN has had 1,940 graduates since 1970 and serves 80% of Minnesota counties. While these numbers are laudatory, we need more primary care physicians trained to take care of the projected shortage of 35,000 by 2025. 16
Shailey Prasad, MD, MPH is the Executive Director and Carlson Chair of Global Health, Center for Global Health and Social Responsibility. http://globalhealthcenter. umn.edu/, Professor & Vice Chair for Education, Dept. of Family Medicine and Community Health, University of Minnesota.
References available upon request.
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