Primary Care–Save Money and Improve Quality?

The enacted health reform bill and many other proposals to improve our health system had as one major assumption the notion that expanding the delivery of primary care would increase quality and lower costs.  Researchers writing in the current issue of Health Affairs test that assumption by a review of existing literature.  (Health Affairs Article) The authors identify three major notions about improving primary care:  one is that there are simply too few primary care physicians, the second is that primary care physicians need more capability and the third is that the whole system needs to be reoriented to significantly raise the role of primary care.  They also find three common definitions of primary care:  the nature of the doctor’s specialty; the actual functions performed by the physician and the orientation of a localized care system.

The researchers note that the studies to date suggest that generally, specialists are actually more likely to follow recommended processes of care than are primary care physicians.  Some studies suggest that for some patients, treatment by a specialist may result in better outcomes, but other studies show no difference.  None appear to suggest that primary care physicians have better outcomes.  Primary care doctors do appear to be less costly and practice less intensively.   In terms of a function of primary care such as creating a usual source of care for a patient, regardless of whether the source is a primary care doctor or a specialist, the evidence suggests that having a usual source results in receipt of more recommended and preventive care, and lower utilization and costs, but the evidence on actual health outcomes is very skimpy.

Systems that are oriented toward primary care, as indicated by primary care to specialist ratios or primary care physicians per capita, generally seem to have better outcomes and lower costs, but even here the evidence is ambiguous and may be confounded.  There are areas of the United States with high primary care physician ratios but also high costs and utilization.  As with almost everything in health care, before we assume that just having more “primary care” is a solution to our problems, more research to identify what really causes higher inappropriate utilization and spending and less adherence to good processes of care and worse health outcomes, would be useful.