Is Primary Care Necessary?

No, it is essential.

At the most macro level it has always been interesting to me that those nations that seem to take better care of their citizens for less money have the exact reverse proportions of providers--greater numbers of primary care providers than specialists; whereas the U.S. has more specialists than primary care. When you make a statement like this you can be attacked for wanting to dumb down the system of care. I know I have been attacked on this for many years.

But it is not a question of smart or not. Sometimes we need the highly specialized knowledge that someone who has focused study and practice on a specific issue can bring. But most of what individuals seek health care advice to address can and should be addressed by a primary care provider. (More in a little bit about how that primary care should be organized.) But when the first or early contact is a specialist of one sort or another, they tend to see the problem in the context of the lens they have, a specialist perspective. There is nothing nefarious about this. Most health care providers just want to help; and they want to provide service in areas with which they have some comfort. Patients also want an answer; and the general orientation of the consumer is that the “specialist” might be able to provide the solution. Often, in complex patients, they can and do.

But when we let the approach to care become fixated on specialty care--as we have in our country--we can de-value the essential health and well being that can be provided by an orientation that integrates an aggressive, deep and wide commitment to first class primary care with a more focused and judicious use of our world leading specialty care.

To arrive at such a balanced state of health affairs we need to advance three policies at the national, state, professional and institutional provider, insurer and consumer levels.

First, we need a more vibrant primary care that integrates itself into the consumer health needs of the nation. Our current efforts to move towards Patient Centered Health Homes is a good first step, but I fear without pushing this concept to and beyond its current limits it will ultimately fail just as the 1990’s flirtation with primary care did. Too much of the movement today is focused on the provider of primary care rather than the primary care needs and desires of the patient as consumer. This profession-centric approach will always fail, as consumers will not be attracted to the value of prevention or alternative management of disease as our efforts in these regards are always seen with the lens of the practice or office, not the consumption patterns of the public.

The first thing that is needed is a very rich segmentation of the primary care consumer market. A well-resourced suburban dweller with tech access and savvy is likely to have a different set of preferences for health care, how it is consumed, organized, financed and delivered, than is a recent immigrant to our nation. These differences are very real and we may expensively burden the first individual with services that are not needed or appreciated and delivered in a clumsy manner, and in so doing may deprive the second individual of a much more intensive and perhaps even intrusive set of services that are needed to maintain or recover health. One individual may need to be prompted continually to receive services and monitored systematically. The other may in fact seek care services in a manner that is timely and beneficial. We play the fool to build one very expensive system, with single standards of excellence and believe that it will equitably serve all 311 million of us. We need more diversity in primary care practice models now, not less. We need to hear and understand what the consumers want and at times are even willing to pay for. We need attention to the service satisfaction level of primary care as much as its clinical outcomes. As unsettling as it is to hear, if some segment of the population can receive more effective primary care at a big box retail outlet, we should rush to make that become reality.

Second, we need the finance and regulation of primary care to drive such a creative response or we will find that in a decade, our good intentions have built a monolithic model of care that is too expensive to sustain and only serves to the average, not the exceptional expectations of patients and consumers. The medical and health care communities in our country are exceptional and are driven by smart, dedicated and creative individuals and organizations. We need the general parameters of where we want to go with primary care, the goals to be achieved, and release this part of our health care system to bring about the transformation. If too much is dictated for compliance, we will arrive at a primary care that performs to the lowest common denominator and again, no provider, consumer, or purchaser will be happy.

Finally, we need a deeper and more fundamental integration between primary care and specialty care. This too should come in a variety of packages. For some models it might be the community health center, for others it might be a staff model HMO; large multi-specialty medical groups have shown one way to success for decades. And even hospital based systems, when they rightly balance specialty care and primary care clinically and financially, have one of the answers. As information technology works its way into our system of health, it will continually offer new opportunities to integrate knowledge among the primary care provider, specialist, support team and patient. Regardless of how it is integrated, we will not realize all of the potential of our vast health care resources without some deeper collaboration between primary and specialty care.

Primary care has never been more necessary and essential to the nation’s health and fiscal well-being. But let’s not put it into old boxes that have just been painted over.