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Key to Health Care Reform: Reinvent Primary Care

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.”


  1. Primary health care relates to the interests of the vast majority of people which decides wheather health care reform could be accepted. High medical costs almost became the characteristics of America. It’s time to reduce it effectively and health care reform is a good chance to relize it.

  2. With their traditional emphasis on health promotion and prevention of problems and complications, nurse practitioners are going to be a big part of this process. Primary care needs to shift from a disease model to a health promotional one. Well, nursing has had that model in place for some time.

    As for the paperwork and denial of coverage problems, as long as we are invested in allowing health care to be run for profit by multiple competing organizations, we will continue to have to expend valuable time, money and energy catering to their competing systems while our patients wonder why we can’t just produce the outcomes for them that they, as the consumers, have a right to expect.

  3. Regina Alexander

    Chey, I can only imagine the difficulty that you have been having in accessing the medical care that you need. Yet, I am confused. I thought that Obamacare would forbid insurance companies from refusing to cover you due to pre-existing condition. My belief is that the healthcare system in the US will be more like Canada and the UK sooner rather than later. I am just saying this since I can only imagine what a burden it would be for you to move to Canada or the UK with your present medical concerns.

  4. While I appreciate the fact that the US is lacking in Primary Care Providers, I don’t see a solution to this problem. My own doctor complains that she spends more than 50% of her time on paperwork and another 10% of her time is spent arguing with insurance companies over their refusals to pay for needed care. Is the Health Care Reform really going to change any of that? What is going to entice soon-to-be-doctors to pick Primary Care as their main objective? Will they get more money? Less paperwork? What?

    I also don’t see that I will be able to afford health care. I have MS and have been refused for insurance for years due to my pre-existing condition. I don’t see anything in the health care bill that says the insurance companies will be required to insure me at a “reasonable” rate. I have always had the option of obtaining health care insurance if I wanted to pay $24,000 a year for it! (BCBS rate in 2009).

    Currently I am considering moving to Canada or the UK to take advantage of their health care systems. I cannot afford to stay in America any longer.

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