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Medicare’s Primary Care Spending

By April 22, 2019Commentary

It is pretty well-accepted that better primary care can keep patients in good health and potentially lower long-term spending.  This supposedly occurs through delivery of more preventive care, early identification of potentially acute episodes and the role of a primary care doctor as a care coordinator.  A new study looks at how much Medicare spends on primary care as a proportion of total spending.   (JAMA Int. Med. Article)   Depending on whether you define a primary care practitioner broadly or narrowly (the broader definition includes nurse practitioners and physician assistants, gynecologists and geriatricians in addition to family practice, pediatricians and internal medicine, so it seems obvious to me that the broad definition is more appropriate) and whether you define primary care services broadly or narrowly; primary care spending ranged from 2.12% to 4.88% of all spending.  In annual dollars per beneficiary the range was $308.32 to $708.23.  Arguably these amounts are not representative of true primary care spending, as they don’t include medications or tests ordered by primary care clinicians.  Those items should properly be considered part of primary care.  Spending as a percent tends to be higher for younger beneficiaries, probably because they don’t have as many serious conditions as older ones.  There was also some variation among states.  I suspect all of this analysis is highly correlated with actual health status.  The authors don’t explicitly comment on whether they view the number as too low or too high, but the implication is that Medicare isn’t spending enough on primary care, given its supposed value.  I am not sure either, but I think this kind of analysis really isn’t very helpful for policymakers.  Many patients with one serious illness may use a specialist for that disease category as a primary care doctor.  Some of the effect on spending is a unit price impact; primary care doctors tend to be much lower paid and reimbursed than are specialists.  If you looked at primary care as a percent of utilization it would be a higher portion of all Medicare utilization than it is a percent of spending.  And there has been some research trying to elucidate the actual impact of “better” primary care, and the results of that body of research are somewhat inconclusive.  Getting patients in better health and achieving better health care outcomes is important, but I am not sure we know yet how much primary care has to do with that.

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