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Primary Care Cost and Quality

By September 27, 2010Commentary

The Dartmouth Atlas of Health Care project examines geographic variation in health care–cost and quality.  The most recent report focuses on the role of primary care, looking for correlations between supply of and use of primary care physicians and various process of care and outcome indicators of quality.  The researchers used the familiar hospital referral region and hospital service area to compare primary care use and outcomes among fee-for-service Medicare beneficiaries.  (Dartmouth Report)

The researchers found wide variation both in the apparent supply of primary care resources and the use of those resources by beneficiaries.  But they also found that there appeared to be little correlation between use of primary care resources and some outcome measures, for example rates of certain diabetes exams or leg amputations.  Greater use of primary care visits also did not appear correlated with ambulatory care sensitive hospital admissions.  The results suggest that even when beneficiaries had access to and used primary care doctors, they didn’t necessarily have better health care outcomes.

Many of the assumptions of making a better health system are being undermined by research results.  The presumed value of primary care is having someone provide continuity and consistency of oversight for all of a patient’s health needs and ensuring that the patient receives basic care for chronic conditions in particular.  For a patient with a chronic disease, however, a specialist in that disease may actually fill that primary care role and may do a better job than a primary care physician would.  The Dartmouth research doesn’t capture that.  In the Medicare fee-for-service world, patients are also completely free to go to whatever doctors they choose to, which makes ensuring continuity of care much harder.  Finally, many patients simply don’t make the effort to take care of themselves, so no matter how much primary care resource is available, it won’t help those patients.  It is not clear that we really need significantly more primary care providers nor does the research always find that use of more primary care improves outcomes.

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