Why Robust Primary Care Is Essential to Health Care Quality and Affordability

by Mark Finch MD, Blue Shield of California

There is a large body of published literature indicating that Americans receive too much care, that is fragmented and unnecessary1. Several studies estimate that in the U.S. approximately 30 percent to 40 percent of health care is unwarranted, which translates approximately to 800 billion in wasted health care dollars2.

As described by Atul Gawande in his widely read 2009 New Yorker article “The Cost Conundrum,” sometimes adjacent communities can be like the tale of two cities: one with low cost, effective care, another with high cost, fragmented and wasted care.

There are many reasons for this enormous squandering of health care resources, but one solution, which most experts agree upon, is that well developed, community-based primary care practice is key to avoiding unnecessary healthcare: personal physicians who engage their patients in their medical care through shared decision-making have lower cost care3.

Studies have also shown that in communities with robust primary care, costs decline and quality increases compared to communities with an over emphasis on specialty care4,5.

If the problem is so clearly identified, and if most experts agree that well developed primary care is important, then why has it not happened? The reasons are that the kind of primary care practice model needed to truly rein in health care spending has to include certain attributes.

These attributes are known as the four pillars of effective primary care6: accessibility, comprehensiveness, continuity and care coordination.

Unfortunately, these pillars have been eroded in many communities because of over-specialization, underrepresentation of primary care physicians, an obsessive focus on hospital-based, technology-oriented health care, lack of system approach in health care, and misaligned reimbursements that over-value procedure-based specialty care at the expense of primary care.

How do we rectify the situation?

First, we right-size the reimbursement to primary care by rewarding outcomes, not procedures. Rewarding outcomes means paying primary care physicians more for:

  • being accessible, seeing patients when they are in need, and allowing walk-in appointments for urgent, but low-acuity illnesses rather than sending them to the emergency room

  • being linked to a specific panel of patients for all of their primary care needs, and overseeing their patients’ care no matter what their venue of care, be it care by a specialist, in an acute hospital, convalescent home, or at the end of life requiring hospice

  • coordinating care by using the primary practice’s entire office staff to communicate with the patient inside and outside the office, during and after work hours if the need arises

  • compiling and maintaining all information on a patient’s health in an electronically portable secure health record

  • ensuring that their patients understand the care they receive, that the care is evidence based, and the preferences of the patient are taken into account when fully informed of their options.

Fixing primary care will not rid all of the waste in health care. However, it is a necessary first step to a patient-centered health care system that engages members in their health care, promotes shared-decision making, and avoids unnecessary care.

Dr. Finch is a board certified Internist and Infectious Disease physician who has been a Medical Director for over 16 years. He has worked in private practice as a primary care physician, managed a large IPA, and worked for two large California health plans to improve health care delivery and efficiency.

1 Wennberg, John E. “Practice Variations and Health Care Reform: Connecting the Dots”; Health Affairs, 7 October 2004

2 Fisher ES, Wennberg, DE., et al. “The Implications of Regional Variation of Medicare Spending”; Annals of Internal Medicine, 18 February 2003

3 Marcille J. “An Evidence Base for Primary Care: A Conversation with Barbara Starfield, MD, MPH”; Managed Care, June 2008

4 Wennberg, David, et al. “A Randomized Trial of a Telephone Care-Management Strategy”; New England Journal of Medicine, 23 September 2010

5 Macinko J, .Starfield B, Leiyu S. “The Contribution of Primary Care Systems to Health Outcomes within Organization for Economic Cooperation and Development (OECD) Countries, 1970–1998”; Health Services Research Journal, 2003 June; 38(3): 831–865.

6 Barr, Michael, et al. “The Advanced Medical Home: A Patient-Centered, Physician Guided Model of Health Care”; American College of Physicians Policy Monograph, 2006