Primary Care: Our First Line of Defense

June 12, 2013

Contact: Melinda Abrams, Vice President, Patient-Centered Primary Care Program, The Commonwealth Fund, mka@cmwf.org

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Imagine if the only place you could bring your child when she develops a fever or an ear infection, or needs a checkup or a refill for her asthma inhaler, was to a hospital emergency room. Or imagine you have multiple medical problems—diabetes, high blood pressure, and high cholesterol, say—yet don’t have a regular doctor you can trust will make sure you’re getting all the right care you need to keep them under control. Primary Care

In other words, imagine how difficult it would be to get all the care you and your family need to stay healthy without a primary care provider.

Whether a family physician, an internist, a pediatrician, or a nurse practitioner, primary care providers are often the first contact we have with the health care system. Practicing in private offices, community health centers, and hospitals, they diagnose and treat common illnesses and spot minor health problems before they become serious ones. They offer preventive services such as flu shots, cancer screening, and counseling on diet and smoking, and play an important role in helping to manage the care of patients with chronic health conditions.

When people don’t have access to a regular primary care provider, they end up in emergency rooms more often, and they’re admitted to hospitals more frequently. Without regular screening, a controllable condition like high cholesterol—which often can be kept in check with common drugs—can eventually lead to a life-threatening heart attack.

The evidence shows that good access to primary care can help us live longer, feel better, and avoid disability and long absences from work. In areas of the country where there are more primary care providers per person, death rates for cancer, heart disease, and stroke are lower and people are less likely to be hospitalized. Another big plus: health care costs are lower when people have a primary care provider overseeing their care and coordinating all the tests, procedures, and follow-up care.

Medical Homes and Medical Neighborhoods

Easier access to primary care is a key to both improving the quality of health care overall and reining in our country’s high medical costs. But making primary care more accessible is just the start. Primary care practices are increasingly becoming the hub of a new model of care known as the patientcentered medical home.

The basic mission of a medical home is to build a close partnership between clinicians and patients—to ensure that we aren’t left alone to navigate an increasingly complex health care system, and that we receive the care most appropriate to our individual needs. This means:

  • Including patients in decisions about which treatment approach is right for them.
  • Enabling patients to see a doctor or other clinician after regular office hours, such as evenings and weekends.
  • Hiring nurses and care managers to follow up with patients after an office visit—to make sure they’ve gotten their medications and know how to take them, for example.
  • Keeping track of when patients need to schedule appointments and when they need prescription refills, and monitoring them if they’ve been hospitalized.
  • Acting as the point person for patients, particularly those with multiple health conditions who are receiving care from a number of health professionals.

All these activities are geared toward a single goal: ensuring that the patient always remains front and center.

Medical home team

To make the medical home the building block of the health care system, physician practices will need to invest in technologies such as electronic health records (more on these below) and Web-based systems for scheduling and communicating with patients online. Clinicians and staff, meanwhile, will need to work together in teams to treat patients with multiple chronic conditions, who require an extra level of care. Changes are also needed in the way health insurers pay for care, so that providers are encouraged and rewarded for delivering a variety of patient services—from answering patients’ questions by email to coordinating with a patient’s other care providers—that lead to better long-term health and lower overall costs.

The Affordable Care Act—the health reform law popularly known as “Obamacare”—contains funding for expanded primary care and for existing medical home initiatives across the country that reach more than a million Medicare and Medicaid enrollees. Many private insurers are also experimenting with ways to reward health care providers for delivering comprehensive primary care.

Medical Homes

For all, the goal is that medical homes will improve health outcomes and reduce the expense associated with a lack of coordination in patients’ care, frequent emergency room visits, avoidable hospitalizations, and the costly move to nursing home care.

To have the greatest impact, a medical home must be located at the center of a “medical neighborhood” inhabited by hospitals, specialty physicians, physical therapists, social workers, long-term care facilities, mental health professionals, and other service providers. It is the role of the primary care provider to coordinate care and make sure that patients don’t slip through the cracks—or receive tests or procedures they’ve already had. This is particularly a concern for patients who see multiple doctors.

One Patient, Two Very Different Outcomes

Take, for example, the hypothetical case of Mr. W., an elderly man with diabetes who lives alone. Mr. W. has a primary care doctor but hasn’t seen her for close to a year—because of his faltering memory and a lack of reliable transportation. During that time, he should have been taking several medications to control his blood sugar, cholesterol, and blood pressure. He was also supposed to be monitoring his glucose on a daily basis.

But Mr. W. doesn’t always remember to take his pills—and, besides, the blood pressure drug makes his skin dry and itchy. He’s also not sure how to read the glucose meter and, already overweight, he struggles to maintain a healthy diet. The result: Mr. W. is now living with poorly controlled diabetes and progressive heart disease—a not uncommon outcome for someone in his situation. Eventually, he is rushed to the ER with a heart attack and hospitalized for a week afterward.

Typically it costs about $12,000 a year to cover an adult with diabetes whose condition is stable. But if the condition is uncontrolled, as is the case with Mr. W., a diabetic person can rack up expenses averaging $102,000 per year, with costs shouldered by a combination of the patient and his family, the insurance company, government programs like Medicare, and sometimes hospitals, if the patient is uninsured.

If, on the other hand, Mr. W. were enrolled in a patient-centered medical home, his story might be very different. First, a nurse care manager embedded in Mr. W.’s primary care practice stays in regular contact with him to find out if he is renewing his prescriptions, taking his medications, and monitoring his blood glucose level. Mr. W.’s electronic health record automatically alerts the practice when it’s time for a checkup or blood test.

When that happens, a nurse or social worker calls and helps arrange transportation to the doctor’s office. A nurse care manager is always available—24/7—to help Mr. W. with his health needs, and talks regularly with his primary care physician to coordinate the care and support they provide.