JAMA study makes case for investing in primary care
- A new study in JAMA Internal Medicine adds weight to the importance of primary care, but says lack of value-based investment is preventing it from fulfilling its promise.
- The researchers compared U.S. adults with and without primary care from 2012 to 2014 on 39 clinical quality measures and seven patient experience measures. The results were aggregated into 10 clinical quality composites. Those receiving primary care had significantly more high-value care, slightly more low-value care and better overall experiences than those without primary care.
- Researchers found no notable difference in volume of outpatient, emergency room and inpatients for patients with primary care and those without. However, those with primary care filled more prescriptions and were more likely to have had a routine preventive visit in the past year.
The study is believed to be the first to compare outpatient quality and experience of people with and without primary care, the authors say. And while it shows benefits from primary care, the association with high-level and low-level care is not always clear.
People with primary care received more high-value care on four of five composites — high-value cancer screening (particularly colorectal cancer screening and mammography), recommended diagnostic and preventive testing, high-value diabetes care and high-value counseling. For example, 78% of adults with primary care got a high-value cancer screening versus 67% who lacked primary care.
The fifth composite, high-value medical treatments such as beta blockers for coronary artery disease, showed similar rates of high-value care between the two groups.
Rates of low-value care were also similar on three of four composites, but those with primary care received more low-value antibiotics.
People with primary care also gave higher ratings for physician communication — 64% versus 54% without primary care.
One reason for the mixed picture could be the lack of investment in primary care, the authors suggest. They note, for example, that of the fourth of adults who lacked primary care, most of them (67%) had health insurance.
"Poor primary care supply or access may be hurdles, or some Americans do not perceive the potential value of primary care, particularly if they are younger … and healthier," the authors write. "These findings contrast with those of other health systems throughout the world; for example, universal primary care registration is required in the United Kingdom and the Netherlands."
Moving away from fee-for-service arrangements and improving workflows could boost the potential of primary care by freeing doctors to spend more time with their patients, Allan H. Goroll, a physician specializing in adult primary care at Massachusetts General Hospital, writes in an invited commentary. Emphasizing outcome measures over process measures and adding interdisciplinary training to help doctors understand care team contributions to care and workflow would also help.
Such reforms could have far-reaching benefits, Goroll says.
"Freed from maximizing volume and supported by a well-functioning multidisciplinary team, primary care physicians would then have time to do the proper workup and complex care management required," he writes. "In addition, they could return to the inpatient setting, where patients would be eager and grateful to see them, not necessarily as the attending physician but in new roles that could range from continuity visitor to consultant to the hospitalist team. Such roles should help personalize care while reducing unnecessary testing, length of stay, and admission rates."
Recent research has shown a decline in primary care in recent years. People with employer-sponsored health insurance showed an 18% decrease in primary care visits between 2012 and 2016, according to the Health Care Cost Institute. Another report from the UnitedHealth Group found that 13% of Americans live an area without enough primary care providers, an issue that is exacerbated by doctor shortage problems. The shortfall among primary care doctors is expected to be between 14,800 and 49,000 by 2030, according to the Association of American Medical Colleges.
- JAMA Internal Medicine Quality, Experience of Outpatient Care in U.S. for Adults With or Without Primary Care