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The editors asked several experts to share their perspectives on the crisis in U.S. primary care. Their articles, which address this crisis from six different angles, follow. We also brought the five U.S. contributors together for a roundtable discussion of the problems and potential solutions for training, practice, compensation, and systemic change. A video of the discussion and reader comments can be seen at www.nejm.org.
Robust evidence shows that patient care delivered with a primary care orientation is associated with more effective, equitable, and efficient health services. Countries more oriented to primary care have residents in better health at lower costs. Health is better in U.S. regions that have more primary care physicians, whereas several aspects of health are worse in areas with the greatest supply of specialists. People report better health when their regular source of care performs primary care functions well. In addition to features promoting effectiveness and efficiency, there are fewer disparities in health across population subgroups in primary care–oriented health systems.1,2
Important functions of primary care include serving as the first point of contact for all new health needs and problems; delivering long-term, person-focused care; comprehensively meeting all health needs except those whose rarity renders it impossible for a generalist to maintain competence in them; and coordinating care that must be received elsewhere. The appropriateness of primary care–based health systems has been endorsed by the Pan American Health Organization and the World Health Organization.3,4
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The United States now ranks 15th to 40th worldwide on various key health measures, such as life expectancy or years of life lost owing to preventable causes. And our rank has been falling steadily, indicating a need to reassess the delivery of services and the balance between primary care and specialty services. Today, more than half of specialist visits are for routine follow-up — a misuse of expensive resources. There are large interregional variations in referral rates and use of specialist services that cannot be explained by differences in patients' needs. Primary care services in most industrialized countries are more comprehensive than those in the United States, where patients are often referred to specialists for problems — such as conditions requiring minor surgery or joint aspirations — that are common in the population and should therefore be addressed in primary care.
There are a number of policy options for improving U.S. primary care. The first imperative is to recognize that the health services system is dysfunctional. Most approaches to reform do not distinguish the use of primary care services from that of specialty services, despite the underuse of the former and overuse of the latter.
Second, perverse financing incentives must be eliminated. Federal subsidies for specialists' training programs now greatly exceed those for primary care physicians — a situation that needs redressing. Encouraging the use of primary care physicians for common health needs instead of specialists in diseases, organ systems, or procedures requires increasing earnings of the former to levels commensurate with those of the latter. In many countries, specialists are paid by salary. In other places, specialist-visit reimbursements are lower when patients are not referred by a primary care physician.
Relatedly, better use of information on the frequency of various illnesses and complications could provide a much-needed basis for understanding when specialist services are warranted. These criteria should focus on the likelihood that patients have uncommon conditions or unusual complications. Primary care management for the vast majority of health problems should be the rule for most diagnosis and care, with specialist intervention when diagnosis requires confirmation with the use of special technology that is impractical to provide in primary care settings. For management dilemmas, primary care physicians can often seek advice from a specialist themselves, obviating the need for direct contact between patient and specialist.
In addition, evidence regarding the benefits of health services interventions in primary care would be more useful if interventions were tested in community-based primary care settings. Primary care practitioners should be the main decision makers about the applicability of clinical-trial results in primary care populations.
Since it will be a long time before U.S. primary care services are equitably distributed, the network of federally funded community health centers should be expanded in areas of shortage. At the same time, we urgently need to standardize insurance benefits to ensure that the benefits of health services are equally available to everyone.
Health challenges are changing. States of increased risk, such as elevated blood sugar level or elevated blood pressure, are now treated as diseases. With conditions being diagnosed earlier and populations aging, the prevalence of various illnesses has increased, their character has changed, and patients with multiple coexisting conditions are common. Still, much of primary care consists of dealing with problems that are never attributed to a specific diagnosis.5 Better patient-level measures, such as physical and emotional signs and symptoms, rather than disease-oriented measures, such as laboratory values, will be necessary to more adequately assess outcomes and the quality of care.
Finally, new approaches to information technology will be needed to facilitate the recording of patients' problems and assessment of their responsiveness to interventions, encourage practice-based learning about interventions' effects, eliminate duplicate and conflicting services through care coordination, and provide for ongoing upgrading of an information base for assessing community health needs and detecting adverse effects, incipient epidemics, and health-compromising exposures.
A stronger primary care infrastructure — with more appropriate, evidence-based specialty care as backup — demands policy consideration if the United States is to improve its international standing in health.
No potential conflict of interest relevant to this article was reported.
Source Information
Dr. Starfield is a professor of health policy and management at the Bloomberg School of Public Health, Johns Hopkins University, Baltimore.
References
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