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It's Primary

Most experts agree that if we want a health care system that is effective, efficient and fair, it should be built around primary care.

In such a system, each person would have a medical "home" based on the principles of prevention, wellness, and timely, evidenced-based care. An integrated team of primary care professionals - physicians, nurse practitioners, physician assistants, mental health professionals, others - would coordinate and monitor the patient's care, and refer out to specialists as needed. The process would be completely transparent and well-documented through an electronic infrastructure available to the patient and all providers. Evidence-based outcomes, not volume of procedures, would be the basis for payment; standards of practice would be continually refreshed through scientific inquiry, and a culture of learning, cooperation and open communication - all centered around the primacy of the patient - would enrich daily practice.

Clearly, this isn't the system we have today. Why not?

• U.S. medical culture devalues primary care and glorifies the specialist. Students pick up on this early on in medical school. In the U.S., it's about a 65-35 percent split between specialists and primary care. In many other countries, primary care physicians comprise 50 percent or more of the total physician population, and the pay differential between family physicians and specialists is much less pronounced. Population-wise, health outcomes are better in these countries than they are here.
• Medicare pays for technology and procedures, not for time. Private plans follow suit. The American Medical Association's Relative Value Update Committee (RUC), which makes recommendations to Medicare on coding for payment, is dominated by surgical, procedural or other subspecialties, and not by cognitive specialties like family practice. So far, all the talk about payment for value replacing episodic process and procedures is so much lip service.
• Medical colleges are dependent on big research grants, which are heavily weighted toward high-tech specialties. The cognitive disciplines bring in less outside support and end up on the lower rungs of the medical education food chain.
• The average consumer doesn't necessarily see the value of having a primary care provider as the first point of contact with the system. Many people see specialists for everything, and especially like making those decisions themselves instead of having a "gatekeeper" do it for them.
• The great majority of physicians practice in small groups, not in large, integrated systems where the medical home concept is relatively easier to implement and monitor, and makes more economic sense.
• Until recently, volume purchasers of health care, such as large employers, haven't engaged health plans and providers on how quality primary care can help to reduce costs and improve outcomes. This may be changing, however, with the increased interest in on-site workplace clinics.
• The dominant fee-for-service (FFS) payment model, combined with small group, cottage industry practice arrangements, makes primary care an unattractive business proposition. The medical home approach needs a critical volume mass to be financially viable, at least under current methods of payment.

The evidence for the value of primary care and the medical home model notwithstanding, it will take more than good reasons to move our health care Titanic off a bloated iceberg of fee-for-service, procedure-driven medicine. High prices, the inefficient use of technology and high administrative overhead may not be justified on principles of effectiveness and efficiency, but they contribute to high salaries and profits for a significant number of players with considerable political and economic clout. Tell the orthopedic surgeon who makes $600,000, the medical dean who makes $800,000, the hospital administrator who makes $1 million, and the health plan executive who makes $4 million that they're not worth that kind of money, and see the reaction you get. They are not about to shift money from their pocket to someone else's unless there's something in it for them.

It takes power to confront power. Those who seek to move America's health care system to one that is more affordable, accessible, effective, efficient and fair will need to mobilize and advocate for the cause. Rational discussion alone won't get it done.

Engage in the fight. It's primary.

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*The Drift reflects the views of the author, and does not represent the official view of SLHI's Board of Trustees and staff.