Primary Care Is Dead!

The death of primary care is upon us.  Such proclamations are not new and there have been numerous pronouncements of primary care’s demise over the past two decades.  Such dismissive attitudes towards primary care and its value to the health care system are not new.  However, a funny thing has happened on the way to primary care’s funeral – it revived itself.

Last month two important evaluation studies were published that demonstrate the value of primary care.  The first was an evaluation of the Comprehensive Primary Care Initiative (CPCi), which is overseen by the Centers for Medicare and Medicaid Innovation (CMMI).  The second was the Patient-Centered Medical Home’s Impact on Cost and Quality: Annual Review of Evidence 2013-2014 from the Patient Centered Primary Care Collaborative (PCPCC).  Both reports show that investments in comprehensive, continuous, and connected primary care produce positive results in both quality and cost.  Furthermore, the PCPCC report demonstrates that those savings are sustainable over multiple years, debunking the so-called “process bias” which asserts that savings are more obtainable in the first year or two, but cannot be sustained over a longer period.

Primary care has enjoyed varying degrees of acceptance and support amongst policy-makers, insurance companies, and the ‘elite’ health policy circles over the past 50 years.  Despite fluctuating support, a simple fact remains true – our nation’s health care system is built on and, relies on, a network of primary care physicians who provide the overwhelming majority of care to our population.  In fact, 55 percent of all physician visits are to a primary care physician.  Today, as a result of these two reports, we have a much clearer understanding of just how important primary care is to our national health care goals.

The CPCi report analyzed year one performances of the 2,158 physicians participating in the program.  It is important to note that 73% of the CPCi participating physicians are in practices with 5 or fewer physicians, further demonstrating that small group practices are capable of delivering quality and efficient health care and should not be forced to integrate with hospitals and health systems.  First year results for the participating practices show reductions in the three primary high cost areas of our health care system – hospitalizations, emergency department visits, and visits to specialist physicians.  The participating practices reduced annual hospitalizations by 2%, emergency department visits by 2%, outpatient emergency department visits by 3%, and visits to specialty physicians by 2%.  They also reduced annual primary care visits in all settings by 2%.

To put these numbers in perspective, we currently spend about $800 billion on hospital-based care and $50 billion on emergency room visits annually.  A 2% reduction in hospital spending would result in annual savings of $16 billion and savings of $160 billion over 10 years.  A 3% reduction in emergency room spending would result in annual savings of $1.5 billion and $15 billion over 10 years.  These are significant reductions in spending and, most importantly, they are achievable.

The PCPCC evaluated the aggregated outcomes from 28 peer-reviewed studies, state government program evaluations, and industry reports published between September 2013 and November 2014.  Of the 28 programs reviewed, 24 found improvements in utilization of health care services, 17 demonstrated improvements in cost, and 11 showed improvements in quality.  The programs reviewed by the PCPCC report are geographically diverse and spread across all public and private payers.

Regardless of the program, the trends were the same as the CPCi program – lower utilization of hospital and emergency department visits, improved access to primary care physicians, and higher patient and physician satisfaction.  The PCPCC report summarizes the current environment quite well when it stated, “The evidence for the PCMH described here (report) underscores the impressive and growing trends that tie the medical home model of care with reductions in health care costs and unnecessary utilization of services; improvement in population health and preventive services; increases access to primary care; and growing satisfaction among patients and clinicians.”

So, some good news, primary care is not dead.  In fact, it is alive and well.  There will always be opposition and much of it will be driven by the financial interest of the “hospital-procedure-repetitive intervention industrial complex.”  This opposition is predictable, but it is meeting resistance by governments, private payers, employers, patients, and primary care physicians who have all concluded that investments in primary care are key to meeting our individual and national health care goals.  These two studies show that given a few resources primary care just might realize its destiny of making our health care system perform at the highest level for patients – oh, and do it for less money. Imagine a patient-centric health care system that provides high quality, timely care and does so without bankrupting individuals, companies and governments.



Shawn Martin is the Vice President for Practice Advancement and Advocacy at American Academy of Family Physicians

Morning Consult