The emphasis on primary care as the “key” to lifting the quality of U.S. healthcare may be exaggerated according to a report, released today, by Dartmouth’s Institute for Health Policy & Clinical Practice.
“Primary care forms the bedrock of a well-functioning, effective health care system,” the researchers observe. But– and this is an important caveat- “simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage, may not be enough to improve the quality of care or lead to better outcomes.”
Wait a minute. In past reports, didn’t Dartmouth’s researchers tell us that patients fare better if they see fewer specialists and more internists?
No. Dartmouth’s earlier studies have shown that when patients see more specialists, care is more aggressive and more expensive, but, on average, outcomes are no better—and sometimes they are worse. This, however, doesn’t mean that primary care, by itself, ensures better care, even if a patient sees her PCP on a regular basis.
As the report points out: “Primary care is most effective when it is embedded in a high-functioning system, where care is coordinated, where physicians communicate with one another about their patients, and where feedback is available about performance that allows physicians and local hospitals to continually improve.”
Policy should “focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals,” says Dr. David C. Goodman, lead author and co-principal investigator for the Dartmouth Atlas Project.
That said, the study’s authors (Goodman, Brownlee, Chang and Fisher) agree that primary care is essential: “Primary care clinicians, whether they are general internists, family practice physicians, pediatricians, physician’s assistants or nurse practitioners, are trained to care for the whole patient. They can diagnose and treat a wide variety of illnesses, help patients avoid getting sick, and ensure that they get the specialty care they need. For chronically ill patients in particular, primary care clinicians serve a crucial role as coordinators of specialty care. They can also help patients control symptoms, slow the progression of their disease, and help manage acute and chronic conditions without resorting to hospitalization.”
But while primary care can do all of these things, this does not mean that it does.
This new study surveys access to primary care—and use of primary care— among the fee-for-service Medicare population in different regions of the country from 2003 to 2007, only to find, once again, that geography is destiny. As the map below reveals, Americans in some parts of the U.S. receive far more primary care than others. During the report period, the share of patients who saw a primary care physician on an annual basis ranged from roughly 60 percent of beneficiaries in the Bronx, N.Y. and Manhattan to nearly 90 percent in Wilmington, N.C. and Florence, S.C.—about a 50 percent difference.
(click map to enlarge)
Management of Chronic Diseases
Yet, here is the first surprise: in those regions where patients have more access to primary care physicians, “this alone does not always keep people with chronic conditions out of the hospital, improve their chances of getting the optimal care recommended for their condition, or improve health outcomes.”
For example, when researchers looked at patients suffering from diabetes they found no relationship between rates of blood lipid testing and eye examinations and whether these beneficiaries with diabetes saw a primary care clinician at least once a year.
There also appeared to be no connection between rates of leg amputation, a serious complication of diabetes and peripheral vascular disease, and whether the beneficiary saw an internist at least once a year. But a patients’ risk of losing a leg did vary dramatically depending upon where he lived –the report reveals a tenfold difference in the rate of leg amputation, ranging from 0.33 per 1,000 beneficiaries in Provo, Utah to 3.29 per 1,000 in McAllen, Texas—the town made famous for over-treatment in Dr. Atul Gawande’s 2009 New Yorker story.
The report also found that having an annual primary care visit did not keep patients suffering from diabetes or congestive heart failure out of the hospital.
In this case, was a more than fourfold difference in the rate of hospitalizations among Medicare beneficiaries, ranging from 30.7 per 1,000 in Honolulu to 135.0 per 1,000 in Monroe, La. (This could be tied to the fact that Louisiana boasts more physician-owned hospitals and surgical centers than any state except Texas. Research shows that when doctors own hospitals, patients are more likely to find themselves in one of them.)
The researchers theorize that “perhaps primary care visits aren’t doing more to improve outcomes” because “the patients most in need of this care are not receiving it.”
But another possible explanation seems, to me, more persuasive: “primary care is most effective when it is embedded within a health care system that allows the coordination of primary care services with those delivered by specialists and hospitals,” the researchers observe. “Unfortunately, most health care providers in the U.S., including primary care physicians, are not organized to do this; many physicians work in small practices, where there is little coordination of care, and communication among a chronically ill patient’s various physicians is often poor to non-existent. Large delivery systems can also fall short in these areas. The quality of the care provided by primary care physicians also varies widely. As a result, patients in regions of the country where they are more likely to have had a primary care visit are not necessarily receiving higher quality care—or enjoying better outcomes.”
Medical cultures vary widely around the nation. In some places, doctors are more likely to work in large mutli-specialty centers where collaboration is a top priority. In other towns, solo practitioners pride themselves on their autonomy. They may play phone tag, but most don’t use electronic medical records—and if they do, these records can’t “talk” to each other.
It’s Not about the Supply of Primary Care Physicians
More primary care does not necessarily mean better care. Perhaps that shouldn’t come as such a surprise. PCPs alone cannot solve the nation’s health care crisis. If we want to keep patients out of hospitals, PCPs and specialists must work together—and they must listen to patients and their caregivers.
If we want to reduce the number of diabetics who wind up losing a leg we should look at the larger problems that affect a diabetic’s ability to manage his disease, putting poverty at the top of the list. Indeed, the report points out that rates of leg amputation for all Medicare beneficiaries differed by a factor of 10. When researchers took a close look at 44 hospital service areas (HSAs) within a single HRR, Atlanta, Georgia, they found a fourfold variation in leg amputation rates.
“Addressing these disparities in health outcomes will require attention to the full spectrum of health determinants,” they write, “ranging from lower levels of schooling and limited health literacy, to inadequate housing and lack of transportation, as well as lack of access to high-quality primary care that is well-coordinated with specialty care.”
That primary care is not a cure-all probably shouldn’t come as a shock. But the report’s second surprise is eye-opening: having more PCPs physicians –more general practitioners, internists and pediatricians–does not necessarily mean greater access to primary care: “Our findings suggest that the nation’s primary care deficit won’t be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage,” says Goodman.
A shortage of PCPs “may contribute to the problem in some locations,” the report notes, but “there is no simple correlation between supply . . . and access,” says Dr. Elliott S. Fisher, a report author and co-principal investigator for the Dartmouth Atlas Project.
The study shows that, in some regions, a relatively high proportion of beneficiaries saw an internist at least once a year, even though overall primary care physician supply was low. This includes Wilmington, N.C., where there were 69.0 primary care physicians per 100,000 residents and 87.4 percent of patients had at least one annual primary care visit. Meanwhile, despite an abundant supply of PCPS in White Plains, N.Y. (101.4 per 100,000), less than 70 percent of beneficiaries saw a primary care clinician each year.
Here, I suspect that the residents of White Plains are simply more likely to go directly to a specialist, rather than consulting a primary care physician first. White Plains is a suburb of New York City, and New York boasts an embarrassment of specialists. (I know, from personal experience that I can usually get an appointment with a Park Avenue specialist within a few days—even if I am a new patient.) Patients in the New York area tend to believe that more expensive is always “better” and of course specialists are more expensive. And while some Americans are wary of “experts,” New Yorkers tend to like the idea of consulting someone at the very top of the food chain. (Many Manhattanites consider themselves experts of one kind or another.)
In addition, primary care doctors in New York, like PCPs in Boston, may keep their waiting rooms crowded by seeing regular patients more often than doctors in some other towns. Again, this is part of the medical culture in Manhattan. If you want to re-fill a regular prescription, your doctor will insist that you come in and see him every three months. If your insurance requires that you get a referral to see an eye doctor, your PCP will tell you that you must come in for an appointment first. Even though he’s not going to exam your eyes, he’s not going to be paid for making the referral unless you see him.
As a result, it’s difficult to squeeze in an emergency—or a new patient. If you call and say you’re experiencing chest pain, your internist will tell you to call an ambulance and go to the ER. (This happened to a friend recently, and stands as an example of the aggressive, expensive approach to health care that Manhattanites have come to expect. He was fine; it may have been indigestion.) Boston is much like New York. A friend there told about the time he cut his hand. His internist couldn’t fit him in. His wife’s primary care doctor couldn’t see him. He wound up having his sister sew up his hand on her kitchen table. My guess is that if my friend lived in Wilmington N.C., and he called his internist, the doctor’s receptionist would say “Come on in—we’ll stitch it up.”
I am, of course, speculating. And these are only anecdotes, but anecdotes can illustrate a medical culture. In addition, Dartmouth data confirms that New Yorkers see many more specialist than patients in Iowa—though our outcomes are no better. The problem in New York so much a dearth of internists as the fact that healthcare in New York City is so fragmented: most of our specialists work solo or in small practices. They value their independence. Many bristle if hospitals try to suggest “rules” or even “guidelines” for best practice. Thus, most surgeons don’t use checklists, even though there is ample evidence that a simple piece of paper can save lives.
Ultimately, this newest Dartmouth study suggests that healthcare, like real estate, is all about “location, location, location.” As the authors put it: “This report highlights the importance of understanding health care within a local context and underscores the need to address the underlying causes of . . . disparities both within and across regions.”
Where You Live Is Paramount
The report acknowledges that both lower-income Americans, and minorities receive less care. Put bluntly, the quality of care you receive varies, depending on who you are. “On average, blacks were less likely to see a primary care clinician than whites—70.4 percent had at least one annual visit in 2003-07 compared with 78.1 percent for whites.” But regional disparities are far greater: where a patient lives turns out to be even more important than the color of his skin. “In the U.S. health care system, it’s not only who you are that matters; it’s also where you get your care,” the authors report. “Regardless of race and income, patients receive care of widely varying quality depending upon where they live and the health system that provides their care.”
If you’re very lucky, you live in a place where the medical culture favors “collaboration” over “competition,” a town where general practitioners, specialists, and hospitals understand that medicine is a team sport. Too many primary care doctors labor alone—working long hours without sufficient support. This is one reason why being a primary care doctor is so difficult. I recall Dr. Donald Berwick , Medicare’s new director, once saying, “No doctor should be alone.” The job is too hard. Insofar as there is a single “key” to raising the quality of U.S. health care, “co-ordination” is, I think, the word to keep in mind.
Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.