Primary care is crucial to lower medical costs

By William T. Branch Jr.,, Minesh Shah and Jada Bussey-Jones


Much confusion has surrounded the recent health care debate. People are anxious about the access of themselves and their families to quality care. Costs rise inexorably.

What if better health care outcomes could be achieved at lower costs? One might think this impossible, but good evidence suggests that a well-developed, highly functioning primary care system lowers costs and improves health. In the United States, the primary care system is underdeveloped and is rapidly deteriorating. We need to rebuild primary care.

Primary care is readily accessible, ongoing, comprehensive care that addresses the large majority of a patient’s needs over time.

Evidence from population studies consistently shows better health outcomes and lower costs in countries, states and counties with more primary care physicians in relation to the population. Studies also show that patients who receive care from a primary care physician are healthier. In these studies, mortality rates of patients enrolled in primary care are lower overall and lower for heart disease, cancer and stroke.

Why does primary care benefit patients? Primary care addresses patients’ overall health as opposed to focusing on a specific condition. Furthermore, most patents suffer from common conditions requiring care well within the scope of practice of a primary care physician. And, primary care physicians address not only the one problem for which a patient may appear, but also the additional problems including prevention. The most important contributors to mortality in the United State are lifestyle issues such as tobacco, diet, exercise and alcohol use. Lifestyle issues are routinely addressed in primary care.

A chief reason for the superiority of highly developed primary systems is the high prevalence of multiple chronic conditions. It has been estimated that 77 percent of physician visits are used by people with chronic conditions. Two-thirds of Medicare spending is for people with five or more chronic conditions. Enfolding the care of multiple chronic conditions under one primary care physician results in better health by addressing all conditions.

This data and logic seem incontrovertible. A more highly developed primary care system would enhance the health of Americans while simultaneously decreasing the nation’s health care costs. Why then is the primary care system degenerating? Between 1998 and 2006, medical graduates filling residency positions in family practice or general internal medicine decreased by 50 percent or more.

Reasons for doctors-in-training to avoid primary care careers boil down to two: financial disadvantage and increased stress. Medical students graduate with large tuition-related debts. The income of primary care physicians as a whole is half or less than that of most specialists.

Today’s young physicians value balance between work and family. They view the choice of primary care as entering a stressful career. Primary care doctors bear the ongoing responsibility for patients, which places great demands on their time. Insurance companies have also created incentives to increase the numbers of patients seen in a day by primary care physicians. This resulted in the proverbial “10-minute visit.” Time pressure defeats the purpose of comprehensive primary care, and increases the stress of practice.

To fix inequities in compensation, we need simple, but politically difficult decisions to adjust reimbursement so that it is reasonably equivalent for primary care as for specialist physicians. This has been argued but has never proved politically possible.

Changing the practice of primary care to make it more rewarding is a more complex endeavor. However, there are promising proposals.

The American College of Physicians, the American Academy of Family Physicians and the American Academy of Pediatrics all propose reorganizing primary care into “the medical home.” This proposal would have primary care physicians working with teams including nurses and other providers to focus on achieving better outcomes by more effective means than simply maximizing the number of patient-visits.

Reimbursement would be balanced between payment for face-to-face encounters and payment for patient education, and improved outcomes of care. Rather than running on treadmills to see as many patients as possible every day, the primary care physician could concentrate on improving the health of all patients under his or her care.

Much more would be accomplished through e-mails, education, classes, phone calls, health care coaching and other means of coordination and communication to improve lifestyles, deliver preventive care and adjust disease management. The doctor would be available to readily see and spend more time with those patients who do need face-to-face care.

The recently passed Affordable Care Act provides a beginning toward enhancing primary care. Among its benefits are some increased reimbursements for primary care, investment in electronic health records, promotion of patient-centered medical homes, broader coverage of preventive services and expansion of health insurance. Taken together, these and other elements of the Affordable Care Act are a step in the right direction.

But the changes fall well short of fully reforming the system. The public requires greater political will than has so far been evidenced by our national leaders.

Dr. William T. Branch Jr., Dr. Minesh Shah and Dr. Jada Bussey-Jones teach at the Emory University School of Medicine.