The U.S. health system is in dire need of dramatic reforms to put patients first, most notably by ensuring that everyone in this country has a formally designated primary care physician to help monitor, navigate, and oversee their medical treatment.
That is the latest recommendation of yet another blue-chip experts’ group: the National Academies of Sciences, Engineering and Medicine, a self-described collective of “private, nonprofit institutions that provide expert advice on some of the most pressing challenges facing the nation and the world.”
An expert panel from the academies, after deep research and in issuing a 448-page report, has expressed disappointment that policy makers seemingly ignored the 1996 recommendations of its independent, nonpartisan sister group, the respected Institute of Medicine. The institute offered a blueprint for moving Americans into an approach, built on primary care, that has shown major benefits elsewhere in the world.
Instead, too many patients in this country get pricey, less than optimal care because they lack sustained, humane contacts and relationships with doctors offering them primary care. This includes not only preventive services but also experience and expertise when they need it in dealing with chronic or serious illness or injury, as well as with a complex, confusing, and costly health care system.
That system now pays by the treatment or service. That creates negative incentives for doctors, hospitals, and other providers to over-test, over-diagnose, and over-treat patients, who can find themselves seeing a dizzying carousel of specialists. They may not see the big picture for individual patients and what may be best for them.
Bob Phillips, director of the Center for Professionalism and Value in Health Care, American Board of Family Medicine, and co-chair of the committee that wrote the academies report, called for strong, excellent primary care to be a “public priority,” adding:
“Primary care serves people throughout their lives, for everything from school-mandated health checkups to managing multiple chronic conditions, but it remains inaccessible to far too many. If we increase the supply of primary care, more people and communities will be healthier — and no other part of health care can make this claim. For this reason, similar to public education, primary care should be a common good, not a commodity service that needs to compete in the marketplace.”
Indeed, as matters now stand, primary care accounts for 35% of patients visits but receives only 5% of health care expenditures (those amount to more than $3 trillion annually in this country). Other industrialized nations spend an average of 14% on primary care. And they are benefiting from building their health systems around primary care, the independent, nonpartisan Kaiser Health News service reported, quoting Melinda Abrams, executive vice president of the Commonwealth Fund, a New York-based foundation that studies health systems around the world:
“We know that better access to primary care leads to more timely identification of problems, better management of chronic disease and better coordination of care.”
KHN also reported:
“Recognizing the value … of [primary] care, many nations — from wealthy democracies like the United Kingdom and the Netherlands to middle-income countries such as Costa Rica and Thailand — have deliberately constructed health systems around primary care. And many have reaped significant rewards. Europeans with chronic illnesses such as diabetes, high blood pressure, cancer and depression reported significantly better health if they lived in a country with a robust primary care system, a group of researchers found.”
Both the academies and the IoM have urged politicians and policy makers to not only tackle the huge challenges of the medical payment and provider reimbursement system but also to boost the pipeline of medical students wanting to become primary care doctors.
That will not be easy, especially as young people rising in medicine see both how badly the U.S. health system struggled with the coronavirus because of its lack of primary care and how the pandemic savaged the finances of primary care doctors.
Reform efforts could get a significant boost, if federal and state programs like Medicare and Medicaid, and big health systems required patients when receiving medical services to designate a primary care doctor. The government could bolster primary care by ensuring its accessibility, for example, in well-run, quality health centers in under-served neighborhoods. Health payers also could bolster primary care by financially supporting teams for it — not just doctors but also the likes of nurse practitioners, pharmacists, and mental health specialists.
In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent health care. This has become an ordeal due to the skyrocketing cost, complexity, and uncertainty of treatments and prescription medications, too many of which turn out to be dangerous drugs.
When dealing with our daunting health care system, primary care doctors can serve as skilled, helpful guides, including in keeping patients out of specialty merry-go-rounds of testing and consultations without useful, accurate diagnoses and productive treatment.
Patients can get weary and fall back into the costly and not always wisest path, say, of thinking a specialist like their cardiologist can serve as their primary care doctor. It might work, as would driving a Maserati around the corner to get a quart of milk. There are better ways, including posing and getting answers to some key questions about your prospective primary care physicians, as I have written.
We have much work to do to improve our health care system, including with our individual choice to build our own and our collective medical treatment around excellent, affordable, safe, and accessible primary care.
