Primary care, primary care, primary care. That is all anyone seems focused on these days, largely in the belief that better primary care is the magic elixir for the health system’s ills. A UnitedHealth Center for Health Reform and Modernization (that’s a mouthful) report discusses and evaluates various approaches to improving primary care. (UHG Report) Primary care is only about 6% to 8% of national health spending but accounts for 55% of all office visits. The number of primary care physicians in an area appears to be associated with improvements in quality outcomes. As might be expected, rates of primary care doctors per population unit are highest where income and insurance status is greatest and lowest in poorer and rural areas. Among the approaches the report explores for expanding primary care capacity are greater use of nurse practitioners and physician assistants, use of multi-disciplinary care teams that can leverage physician skills and greater use of health information technology to create efficiencies in care processes (good luck with that one since there is about zero evidence that HIT helps, in fact seems to create inefficiencies). UnitedHealth gives examples from its own network of success with the medical home and ACO concept, which are two of the hottest versions of primary care reform, but acknowledges that the evidence for success in improving quality or lowering costs is non-uniform at best. Other approaches to expanding and improving primary care include the growth of retail and onsite clinics, telemedicine, home visits, group visits and focusing on high-cost patients. As the report notes, it is unlikely that any one of these will bring about the desired improvement but collectively they may move things in the right direction. The most impressive results are found in some Medicare-focused primary care clinics, where detailed attention to care processes and care models and very active intervention with patients has shown substantial reductions in overall spending, particularly in regard to inpatient use, and improved performance on quality measures. So it is possible to have an impact on primary care, but one question is whether the costs can be justified across the entire population or just for some relatively high-cost sub-segments.
