Op-ed: Ways to make primary care the key to health reform

The following op-ed, co-written with Rahul Parikh, was published on December 16th, 2009 in CNN.com.

America is closer to meaningful health care reform than at any time in its history. As we have all witnessed, finding a way to both provide every American access to affordable health care while seeking to control health care costs has not been easy.

Many of the proposed solutions have led to sharp disagreements, with contention surrounding what role government should play.

One goal all sides can agree on, but have yet to meaningfully address, is the need to end the crisis of primary care in the United States.

Without taking steps to fix it, any attempt at reforming our health system cannot succeed.

Consider that the number of patients without a primary care doctor is estimated to be 60 million, according to the National Association of Community Health Centers. Most patients want their medical care to be consolidated at a single office, provided by clinicians who know them well. In a survey from the Journal of the American Medical Association, 94 percent of patients preferred seeing a primary care doctor first for their medical issues.

But in most cases, patients wait weeks or months for a primary care appointment, which often leads them to the emergency department for care that ordinarily can be handled in a doctor’s office.

While nearly all primary care doctors in the United Kingdom, New Zealand, and the Netherlands offer office visits after hours, only 29 percent of physician offices in the United States offer comparable care, forcing more patients to go to the ER.

Many solutions propose to rectify the economic factors, such as lower salaries, that discourage medical students from pursuing careers in primary care medicine. But there is scant discussion of rebuilding our health care system around the primary care doctor-patient relationship. To achieve this, three ideas are essential: teamwork, technology and integration.

Creating effective teams can help doctors focus on patients’ well-being. At the Medical Associates Clinic and Health Plans in Dubuque, Iowa, for instance, support staff at all levels work closely with doctors and patients to ensure a productive encounter.

Nurses huddle with their doctors prior to each visit and summaries of patients’ lab tests, notes, current medicines and problems are reviewed. Receptionists are also involved, scheduling lab tests before and after encounters to ensure that doctors and patients have the information they need at each visit to change the plan of care.

General practices in the United Kingdom use a similar team-based approach, and studies show that such teamwork is associated with improved care for patients with diabetes along with better continuity of care, access to care, and patient satisfaction. By contrast, according to a recent Commonwealth Fund survey, “U.S. physicians have not led in implementing … the use of teams.”

Technology already plays a prominent role in medicine. But much of it, like imaging scanners and robotic surgery, is used by specialists to diagnose and treat illness. In contrast, primary care doctors rely on these high-tech tools sparingly. Yet technology can strengthen the relationship between physicians and patients by improving access and convenience for both.

One example is simple e-mail, which is beginning to make inroads in health care. A study from the University of Pittsburgh School of Medicine showed that parents who used e-mail to communicate with their child’s physician increased access and improved the quality of care.

Parents did not report that e-mail distanced them from their child’s doctor and physicians found that answering patient e-mails was 57 percent faster than using the phone.

Finally, if we build a health care system around the primary care doctor’s office, then all other facets of care must be integrated with it. Specifically, involving specialists in the primary care experience can provide comprehensive care efficiently.

At Kaiser Permanente in Northern California, specialists have introduced “p-consult” to provide this kind of integration. When a patient comes to see their primary care doctor with a problem that requires specialist input, the primary care doctor can call the specialist immediately from the exam room for consultation.

Both primary care doctors and patients report that the program helps them get care right the first time, avoiding redundant visits and tests that drive up costs. For specialists, “p-consult” helps keep their access open for patients who need to be seen.

According to the World Health Organization, health care systems centered around primary care have lower costs and better outcomes, which Congress has recognized by acknowledging the need for reducing the gap between what primary care doctors and specialists are paid. However, ideas to make it easier to deliver primary care and strengthen the doctor-patient relationship need to be at the forefront of the health reform conversation.

Improving primary care in America needs to be about more than the money.