Successful health care reform relies on building up primary care infrastructure, particularly in moving to more comprehensive models such as the patient-centered medical home.
That’s the conclusion of researchers Robert Phillips, M.D., MSPH, and Andrew Bazemore, M.D., MPH, in “What is Primary Care and Why It Must Be Central to U.S. Health System Reform” in the May 4 Health Affairs special edition, “Reinventing Primary Care.”
Phillips, director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, and Bazemore, Graham Center assistant director, write that primary care-based health systems throughout the world produce better patient health at less cost than the U.S. system. That’s because these systems are founded on primary care as defined in the 2008 World Health Report: A system founded on team-based, comprehensive, and whole-person care that integrates services across the health care system, provides continuity, acknowledges the patient as an integral part of the health care team, and bridges personal, family, and community health programs.
“Decades of implementation and experimentation reveal that primary care is central to the functioning of health systems in many countries, where it is offered more consistently than in the U.S.,” write Phillips and Bazemore. Among the examples they cite is the 1986 reformation of Spain’s health care system, which today spends about half — 8.4 percent of its Gross Domestic Product — as the United States on health care and has half the U.S. infant mortality rate.
Primary care physicians represent 30 percent of all doctors in the United States, but that percentage is shrinking. Subspecialists account for the remaining 70 percent. U.S. health care spending comprises 16 percent of the Gross Domestic Product — more than any other industrialized nation. Despite that cost, the World Health Organization reports the United States ranks 37th in overall health care and system performance worldwide, in last place among 19 industrialized nations on mortality that could have been avoided if patients had received appropriate health care, and in last place on infant mortality when compared to eight industrialized countries that report infant mortality using the same methodology.
“As primary care takes root elsewhere, the lack of its implementation in the United States is cited as a key reason why the United States falls farther behind in population health measures and continues to have wide disparities of health outcomes within its population,” Phillips and Bazemore write.
Increased investment in the health care models such as the patient-centered medical home is essential to improving health outcomes for individuals and communities, reducing disparities in health care, and reducing health care spending, according to Phillips and Bazemore. They write that one important investment would be establishing a primary care extension program similar to USDA cooperative extension agencies. Authorized under health care reform and awaiting Congressional funding, a primary care extension program would provide information and resources that guide physicians as they transform their practices.
“Early demonstrations of the patient-centered medical home … are illuminating pathways,” they write. “But the pathways are only achievable on a national scale through payment reform and change facilitation. Recent health reforms in the U.S. offer some of these, but realizing the full fruits of primary care will require more focused and far-reaching reform.”