The ACP Advocate Blog

by Bob Doherty

Wednesday, September 15, 2010

Has primary care been "oversold"?

Citing a new study by the Dartmouth Atlas, the Wall Street Journal’s health blog provocatively asks "Has the notion of 'access' to primary care been oversold?"

The Dartmouth researchers found "that there is no simple relationship between the supply of physicians and access to primary care." That is, they found that having a greater supply of primary care physicians in a community doesn't mean that the community necessarily has better access to primary care. Some areas of the country with fewer primary care physicians per population do better on access than other areas with more primary care physicians.

The researchers also report that the numbers of family physicians is more positively associated with better access than the numbers of internists, although they call the association "not strong." Although both general internists and family physicians are counted as primary care clinicians, in [regions] with a higher supply of family physicians, beneficiaries were more likely to have at least one annual primary care visit.. In [regions] with a higher supply of general internists, fewer beneficiaries had a primary care visit on average."

The study also suggests that the availability of primary care doesn't always lead to better outcomes:

"For example, leg amputation is a serious complication of diabetes and peripheral vascular disease. A broad array of factors go into a patient’s risk of amputation, including obesity, smoking, poverty, and poor control of blood sugar, and preventing amputation requires diligent attention from both the patient and clinician. One might assume that, at a regional level, access to a primary care clinician would be a predictor of the risk of amputation. Yet ... improving this outcome of peripheral vascular disease is much more complicated than simply ensuring access to primary care; there is no relationship between having at least one annual visit with a primary care clinician and the rate of leg amputation."

So does this mean that ACP and others who have for years have argued that primary care is positively associated with better outcomes, access and lower costs have had it all wrong? I don't think so. There are scores of studies that show that primary care is associated with better outcomes and lower costs of care.

And a careful reading of the Dartmouth study shows that the researchers share the belief that primary care is the "backbone" of health care, that "primary care physicians can play a crucial role in ensuring that patients get high-quality care" and that "primary ... care that does a good job of managing chronic disease can prevent hospitalizations."

What's the story, then? The main point of the Dartmouth study isn't that primary care doesn't matter - it does - but that it is much more than a numbers game.

Dartmouth suggests "that primary care is most effective when it is embedded within a health care system that allows the coordination of primary care services with those delivered by specialists and hospitals." This is one reason why ACP has been so insistent on championing the concept of the Patient-Centered Medical Home, which has as a central purpose facilitating coordination of care through a well-organized primary care practice that has relationships with teams of nurses, physician assistants and other specialists.

My answer to the Wall Street Journal health blog question - has primary care been oversold? - is an emphatic, heck no! But the study does remind us that as much as we need to ensure a sufficient supply of primary care physicians, we also need to learn how to organize primary care to achieve the best results, such as through Patient-Centered Medical Homes. My concern is that policy-makers may instead simplistically point to the Dartmouth study as a reason not to invest more in training and retaining primary care physicians.

Today's questions: What is your reaction to the Dartmouth study? And how would you answer the Wall Street Journal blog's question: has access to primary care been oversold?

10 Comments :

Blogger Roy M. Poses MD said...

One chronic problem with the Dartmouth atlas approach is their use of outcome data without adequate controls for all the factors that may confound these outcomes.

There are myriad possible factors that may influence whether a diabetic patient ends up with an amputation. These factors may differ across patients seeing different doctors, in different health care systems, or in different regions. Figuring out all the relevant factors and controlling for them is notoriously difficult.

The factors mentioned in the quote above as possibly predicting amputation only scratch the surface.

Patients with different characteristics that affect the likelihood of this outcome may also differ in access to primary care.

How could the Dartmouth researchers be sure that the outcomes of patients with different levels of access to primary care were not due to differences in factors they did not measure?

September 15, 2010 at 3:16 PM  
Blogger Jay Larson MD said...

The Dartmouth Atlas study leaves me with more questions than answers. Were the providers actual primary care providers? How many providers were physicians versus physician extenders? Does the number of physician extenders affect health outcome the same as the number of primary care physicians?

Over 20% of the family practice physicians (who would be considered primary care providers in the Dartmouth Atlas) in our community work in Urgent Care Clinics. The same “Office” visit E&M codes are used for services provided by true primary care physicians who follow patients longitudinally as Urgent Care providers who only see patients cross-sectionally. So billing data can't separate out how the physician is practicing. How many “primary care providers” in the study worked in offices doing primary care versus Urgent Care clinics?

Were enough communities of various sizes (urban, suburban, rural) studied to come up with any solid conclusions?

Has the changing roles of the primary care providers (more administrative burden and less time for direct patient contact) affected the benefit of primary care?

Has the impact of dealing with more patients without office visits (ie more prescriptions per patient to fill, more prior authorizations per patient to fill out, more diagnostic test results to review, more phone calls and e-mails from patients) per day affected the benefit of primary care?

The study did reveal that quantity and quality are 2 different matters. I am still of the belief that if primary care is done well the outcomes are much better.

The health care system is dynamic and a snap shot will not give an accurate picture. Whether or not primary care is being “over sold” will pan out over time because the breed is dying out…especially general internists doing primary care. We’ll see how the health care system fairs without general internists doing outpatient care of patients with multiple chronic diseases. Our community will be down to 4 general internists at the end of the year, down from over a dozen 20 years ago. In our community, those with multiple chronic medical problems are having a difficulty time finding physicians willing to take on their medical care.

September 15, 2010 at 6:34 PM  
Blogger Arvind said...

The answer to this question is a qualified "yes". The way it is "oversold" is how the ACP projects it, i.e. in an isolated manner. Primary care can succeed in keeping complications of chronic disease to a minimum only with strong and meaningful interactions with various specialists such as Endocrinologists, Ophthalmologists, Podiatrists, etc. Unfortunately, the ACP has done a poor job making this a priority, in the interest of promoting generalists.

As far as this specific example of diabetes is concerned, the factors that help in prevention of complications must include the patient/caregivers/family in addition to pharmacists, Registered Dietitians, Certified Diabetes Educators.

Ironically, the only mechanism by which comprehensive co-ordination of care could be compensated, i.e. Consultation Codes, were abolished, with tacit approval/support from the ACP. Sorry to say, Bob, but nobody will do extra work without appropriate reimbursement, especially when it is already pre-fixed and heavily discounted.

Diabetes management involves intensive work and outcomes depend on the efforts of both patient and physician. Of course, the ivory tower academics at Dartmouth cannot measure these variables, can they?

September 15, 2010 at 9:21 PM  
Blogger DrJHO7 said...

As long as there have been patients, there have been physicians who provide primary medical care (3PMC). These physicians have provided most (85-90%) of the medical care that their patients have needed. The evidence base for the effectiveness of 3PMC in improving patient outcomes and reducing the overall cost of medical care is substantial and is reviewed in this ACP policy paper
http://www.acponline.org/advocacy/where_we_stand/policy/primary_shortage.pdf from 2008.

The Dartmouth atlas data may depend on which medical community(s) were looked at and how medicine is practiced in those communities, and what medical resources are available, what the demographic and clinical characteristics of the patients is like, etc.

Whether physicians are in solo, small, medium, large practices, integrated delivery systems, PCMH's, ACO's, whatever, is not so important as is HOW they practice medicine - how they communicate with their patients, and how they communicate with their colleagues and interact with other components of their local health system in the care of their patients. There is considerable heterogeneity between medical practices and medical systems and how they function across our country. Bigger is not necessarily better.
It's how you do it that counts. The crux of the biscuit is communication, and information sharing, on multiple levels. That's how you take good care of patients.

PCMH, or the other practice models, might make primary medical care better in some ways and in some places, but PCMH is still warming up on the launchpad and may not have widespread applicability, especially if it's not adequately funded.
An improperly funded PCMH would be an administrative and overhead nightmare for anyone in private practice.

Primary medical care needs to be the backbone of a successful health system. With the complexities of our health system today, most patients need a personal physician to be the captain of their ship, provide most of their health care needs, and help to coordinate their care when necessary. It can't be oversold, anymore than the sun can be oversold as the center of our solar system.

September 16, 2010 at 12:09 AM  
Blogger Steve Lucas said...

I view this question from the perspective of having traveled and spoken to people from the EU, often sighted as having equal of better outcomes at a lower cost than the US.

One major difference is that in the EU you go to the doctor when you are sick. Access varies from country to country, but there is no incentive to churn the practice, so contacts are limited. Often we find people in the US on a 90 day office visit cycle, only to have a BP reading and be sent on their way. With some practices seeing 70 patients per day, people are having contact, but no meaningful interaction.

In a legal action earlier this year in my community, it was discovered that at least one hospital was paying a large medical practice $25,000 per doctor for exclusive testing referrals. It is not a great leap to assume there was a great deal of unnecessary testing, or at least testing being done with expected results.

We need to distinguish between patient contact and meaningful interaction. Churning a practice will produce contact, but not necessarily meaningful interaction. There is a growing realization in the medical community that financial incentives are distorting the contact/interaction equation.

With so many variables contact and outcomes can not be used as a sole determining factor in measuring success.

Steve Lucas

September 16, 2010 at 8:03 AM  
Blogger Robert J. Sobel, M.D. said...

Lots of data out there that can be hard to interpret. I am in strong agreement with Roy, Jay, and Dr. JHO7. It reminds me of analyzing data from individual type 1 diabetic patients. Averages and trends can show up, but it is really analysis of the raw data that enlightens. The new sensors are demonstrating this as well.

Bob has certainly covered this territory before and I think has effectively defended the role that primary care has historically had, international norms, and our distorted ratios in this country. The Dartmouth data reflects Medicare, which may enter its own variable. While I hate to agree with Steve's portrayal of the worst of modern medicine, I do believe the chronic under-reimbursement in Medicare has had its effect on physician behavior. It is extremely difficult to get fair reimbursement for the effort involved in caring for complicated patients. Sharing their care with others is not some automatic panacea. Maintaining appropriate surveillance in domains outside of the internist's usual skills (Ophthalmology, foot care when abnormalities exist) is obviously important. The idea that most patients, however, need routine conference calls amongst their specialist physicians is a bit fallacious. We can certainly churn compartmentalized evaluations, but a lot of that care could be provided by a competent internist.

As for Arvind, I believe we share a specialty. There are other ways to attempt to get reimbursed for diabetic care (education or self-management codes if you have an "embedded" educator, a margin on the necessary lab evaluations achieved efficiently and prudently), but it is becoming more and more difficult.

The advent of administrative mandates (information technology, quality measures) and medical homes will not help the cause of independent private practice. The beauty of medicine was the fact that decisions are made by consenting individuals after careful deliberation. The current incessant interference based on pharmacy-benefit demands, insurance cost control strategies disguised as quality compliance efforts, and anti-fraud counter-measures that demean patients and physicians are not helping the cause.

No, primary care has not been oversold. Reform has been. We are effective when given the opportunity. We are reimbursed fairly in an inconsistent manner, and very rarely from the public payors. We use our desire to help the patients to drive the $300 billion pharmaceutical industry. We get squeezed as Medco and Express Scripts roll up $300 million quarterly in profit.

There are definitely problems. Let us quit producing false solutions.

September 16, 2010 at 11:38 PM  
Blogger Paul said...

Well I think this was the same conclusion the Future of Family medicine came up with -- Primary care needs to deliver comprehensive, integrated, coordinated and accessible care needs to be as the President said June 8th 2010 -- Primary care empowered to be the HUB where patient center care is delivered.
That is why we want to change the covenant around the care we buy of care in the Patient centered Primary care Collaborative and in the Joint principles . In listening to Elliott his focus is on making sure that primary care is back stopped by a village, a neighborhood, an accountable structure that empowers Primary care to do deliver comprehensive, integrated, coordinated and accessible care.
But on the other hand primary care needs designed and paid to achieve much higher performance than it achieves currently. Such a redesign of primary care is possible today.
However, and i am sure Elliott agrees -- if primary care is not successful in its core tasks of prevention, wellness, and the care of common conditions including many chronic conditions, it will not be possible to control either quality or cost of care in the United States. Again, hospital care and Part-ecialty (specialty) care are crucial to health care, but their use is all too often the failure of upstream care. And look we have to start somewhere lets get really focused and address this lack of a foundation in are primary are delivery system and build onto a PCMH the better hospital and Part-ecialty we also need.
For the first time in history, we have both the knowledge and the capabilities (if we work hand in hand with our primary care providers) to force together substantial change. We are at a unique time in the history. In five or ten years, we might well look back with amazement at the pace of the changes that are currently taking place. The route is clear: We know what to do. We know how to make the system better. The crucial question is whether we have the courage to take on this difficult solution. But are strength lies in the fact that the primary care physicians want to help us take this on a wholesale transformation at the Micro primary care. Primary care is the big key to all this transformation it is the foundation and I am sure Elliott agrees he is just concerned it will get washed away if not a restructured to deliver patient centered medical home (PCMH) level care and covered by a roof and infrastructure of accountability. He is so concerned you can see it in his eyes when he speaks -- that with out an accountable neighborhood to support primary care our nations will fail in the transformation mission we have to have.


Paul Grundy, MD, MPH
IBM's Global Director of Healthcare Transformation
President, Patient-Centered Primary Care Collaborative

September 18, 2010 at 8:08 AM  
Blogger Paul said...

But on the other hand primary care needs designed and paid to achieve much higher performance than it achieves currently. Such a redesign of primary care is possible today.
However, and i am sure Elliott agrees -- if primary care is not successful in its core tasks of prevention, wellness, and the care of common conditions including many chronic conditions, it will

not be possible to control either quality or cost of care in the United States. Again, hospital care and Part-ecialty (specialty) care are crucial to health care, but their use is all too often the failure of upstream care. And look we have to start somewhere lets get really focused and address this lack of a foundation in are primary are delivery system and build onto a PCMH the better hospital and Part-ecialty we also need.
For the first time in history, we have both the knowledge and the capabilities (if we work hand in hand with our primary care providers) to force together substantial change. We are at a unique time in the history. In five or ten years, we might well look back with amazement at the pace of the changes that are currently taking place. The route is clear: We know what to do. We know how to make the system better. The crucial question is whether we have the courage to take on this difficult solution. But are strength lies in the fact that the primary care physicians want to help us take this on a wholesale transformation at the Micro primary care. Primary care is the big key to all this transformation it is the foundation and I am sure Elliott agrees he is just concerned it will get washed away if not a restructured to deliver patient centered medical home (PCMH) level care and covered by a roof and infrastructure of accountability. He is so concerned you can see it in his eyes when he speaks -- that with out an accountable neighborhood to support primary care our nations will fail in the transformation mission we have to have.

Paul Grundy, MD, MPH
IBM's Global Director of Healthcare Transformation
President, Patient-Centered Primary Care Collaborative

September 18, 2010 at 8:11 AM  
Blogger southern pcp said...

But, Dr. Grundy, if I spend 4 hours with an IBM employee coordinating care, reviewing and making appropriate referrals, ordering and analyzing studies, arranging all followups, prescrbing meds, completing pre-auths, ordering in-home services, laying out a long term plan of care, and updating all health maintenance needs, I get paid zero dolarrs and zero cents.

You get what you pay for: short, superficial, episodic care.

September 22, 2010 at 10:18 AM  
Blogger Harrison said...

Primary care physicians should be paid more.
New doctors will not choose primary care unless they see that the income expectations are improving.
The government is the largest payer source for primary care services. The option of accelerating the federal government budget for health care is a major problem going forward, and so the budget will almost certainly be kept neutral.

So the patient centered medical home is aimed at: Increasing salaries in primary care, limiting health care expenses over all, and improving the patients' encounter with the health care system in terms of quality and safety.

That's a lot to expect from something that most of us can't even define (or at least that we can't agree on a definition).

Lets consider the sentiments of the Tea Party.
They hate health care reform.
Why?
Well, I'm not one of them and so I probably won't do this justice but this is what I think.
They hate the idea of government coordination.
They don't believe that social design can start at the top, and they consider this to be an exercise in social design.
They would favor a withdrawal of government from health care.
This would allow, over time, the development of patient and primary care doctor relationships based on the market.
People would go to primary care doctors because that is who would fit in their price range.
They would seek out those services in preference to jumping to a specialist who they could not afford.
Kinda makes sense.
But we've gone perhaps too far along the path of patients not being accountable to imagine that system.
And that system would leave a lot of people without access to health care.
And quality and patient safety would probably suffer -- at least initially.

If we stay with the top down control system that we already have, then the current health care reform measures are gonna have to be more generous to primary care, and they are gonna have to be a bit more activist (or regulatory) in how to define a patient centered medical home.

Maybe this exercise in social design will work.

Harrison

September 22, 2010 at 2:48 PM  

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Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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