Primary Care: The Bedrock of Health Care Reform


In previous blogs and in my book, we have discussed the value of primary care to the health care delivery system. Primary care doctors—the lowest paid of all physicians, sometimes earning as much as $200,000 per year less than their more specialized colleagues—provide the highest value of all physicians. In areas of the country with a higher proportion of primary care doctors to specialized doctors, outcomes are better, costs are lower, and satisfaction is higher. Patients who have a primary care doctor do better and cost the system less than patients who do not have regular primary care. The benefits of primary care are even more pronounced when practitioners have enough time and resources to take care of their patients, as Steve Schimpff shows in his book, Fixing the Primary Care Crisis. In fact, a concierge model, where primary care doctors take care of a limited population and are paid per patient rather than per visit, is the most effective means of assuring efficient and high quality health care.

Two recent articles demonstrate the benefits of primary care and are worth reading. Atul Gawande’s “The Heroism of Incremental Care” in the New Yorker shows both how valuable primary care is, and how the health care delivery system is neglecting primary care. As we have demonstrated many times, medical resources—both in terms of physician salary and ancillary assistance—are dropped upon the laps of specialists and hospitals that provide both low value and heroic care, something Gawande well illuminated in a prior article, “Overkill.” Primary care doctors can handle over 95% of medical problems their patients confront, and are singularly qualified to provide the best preventive and curative care to each individual patient who they typically know very well. In any well-functioning health care system, there would be ample primary care doctors who have the time and resources to take care of their patients, and they would be paid for their value to the system, making them among the highest paid medical practitioners. That, of course, is the very antithesis of our current health care delivery system as and of what both liberal and conservative reformers seek, as i discuss in my RealClearHealth article and my recent Washington Times op-ed.

The second article by Danielle Ofri in The New York Times is entitled “The Conversation Placebo.” In her piece, the author describes how the benefit of primary care occurs simply by enabling discussions between doctor and patient over many years. The relationships primary care doctors develop with their patients facilitate better and clearer communication, alternative means of confronting chronic illness other than the over-treatment often prescribed by specialty care, and an emphasis on prevention. Sometimes the mere empathy and caring that primary care doctors show is enough to mitigate many medical problems. Of course, such a “conversation placebo” is predicated on the fact that primary care doctors have enough time to actually converse with their patients in a meaningful way. Our current environment in which these lowest-paid doctors now must be concerned with properly utilizing their electronic medical records (EMR) and filling out scores of quality indicators for them to achieve their “quality” bonus money from insurances like Medicare, is antithetical to doctors being able to spend sufficient quality time with their patients. And as we see in the next blog, such quality indicators and EMR compliance adds nothing to health care and patient value; they only get in the way of the conversation. We will talk in a subsequent blog about methods that are being proposed to change this equation and elevate primary care to the level where it should be in the health care delivery system.

I recently attended a conference in Boston of the Right Care Alliance (RCA). The RCA is a group of doctors, nurses, patients, administrators, patient advocates, journalists, and many others advocating for a more sensible and inclusive health care delivery system. The RCA is nonpartisan, and its leadership and members are a passionate and devoted group willing to work with any leaders to impact the health care debate. They believe that primary care must be the bedrock of any successful health care delivery system. Several RCA members recently published a series of articles in The Lancet, and have delineated their core values on their website at www.rightcarealliance.org. In this era of medical chaos, with both political parties unable to construct a sensible health care delivery system in the wake of the ACA’s demise, lend your voice to the discussion. I currently co-chair the primary care council of the RCA, and would appreciate anyone interested to sign up for the RCA and for the primary care council and any other councils of interest. It is very clear that primary care is an essential part of health care reform, but its value is diminished by the status quo and the current “reforms” being thrust upon their practitioners’ backs. Let’s work together to sew some sense into health care, starting with primary care.

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