Primary Care, Which Saves Lives, is Struggling to Survive

November 2, 2022

Summary: Evidence from around the world and in the US confirms the value of primary care for health care access, quality, and outcomes. Yet through inadequate financing we cause its shrinkage and stresses over time. Single payer would remedy this critical imbalance.

Is Primary Care in Critical Condition?
Medical Economics
October 28, 2022
By Timothy Kelley

In 2006 the American College of Physicians (ACP) declared that primary care, “the backbone of the nation’s healthcare system, is at grave risk of collapse.” That year, in a landmark New England Journal of Medicine article, Thomas Bodenheimer, M.D., M.P.H., a professor at the University of California, San Francisco (UCSF) and founding director of its Center for Excellence in Primary Care, identified “a confluence of factors that could spell disaster.” Patients are increasingly dissatisfied with their care, he wrote, and primary care physicians are unhappy with their jobs. “The quality of care is uneven; reimbursement is inadequate; and fewer and fewer U.S. medical students are choosing to enter the field,” says the Bodenheimer jeremiad.

Other countries seem to get it even if the U.S. doesn’t. Study after study has shown that other wealthy countries outperform the U.S. on almost any healthcare metric you might imagine while devoting a far smaller share of their gross domestic product to healthcare. One explanation: They put more emphasis on primary care. 

With an extra medical assistant on the core team working as a scribe, says Bodenheimer, physicians can see more patients because they’re relieved of many of the documentation tasks that overwhelm their days and that they often take home to work on after a long workday is over. The nonphysician members of interprofessional teams, he says, can save physicians even more time by seeing some patients themselves “if you let them do what they’re capable of doing,” he says. Some studies have shown that pharmacists can do a better job of taking care of people with diabetes than physicians and that physical therapists can do the same for people with musculoskeletal problems, says Bodenheimer.

However, recent innovations such as the accountable care organization (ACOs) and the patient-centered medical home (PCMH) have failed to transform primary care as many had envisioned …. PCMHs, in particular, get low marks from Bodenheimer: “They’ve been pretty much a flop.” 

Bodenheimer notes that annual U.S. healthcare expenditures totaled more than $4 trillion in 2020, with just 5% of that spending going to primary care compared with 12% in European countries. “Primary care really should get 10% of the healthcare dollar rather than 5%,” he says. “If we do that, we’ll have enough money to hire the people — the nurses and pharmacists and physical therapists, for example — to be on teams that can help the physicians take care of their overly large panels and make life a lot better for the physician. And that would attract more medical students to go into primary care and could reverse the whole downward trend.”

So there it is. Just move $200 billion around, and you’ll get many more physicians eager to embrace what is arguably U.S. healthcare’s most crucial, most problematic — and potentially most rewarding — challenge.

Comment by: Don McCanne & Jim Kahn

There is a consensus that we should be doing better with primary care if we want to achieve our goal of higher quality care for everyone and better outcomes. International evidence supports this. And within the US more primary care translates to lower mortality.

However, our health care infrastructure is set up with models catering more to the business of medicine rather than to the medical care of the patients.

Tom Bodenheimer suggests that the answer is in spending health care dollars more appropriately on the primary care team designed to provide optimal care rather than on service models more appropriate for building income and wealth.

He has been distributing his message for some time now. Isn’t it time that all of us become more aggressive in applying it?

Single payer would permit us to support and grow primary care through appropriate financial support and reward for this fundamental pillar of health care.