Primary Care Has Critical Impact on Health Care Outcomes

Legislation that underscores the critical role of primary care by providing support for the patient-centered medical home, aligning incentives to embrace value over volume, and ensuring the adequacy of the primary care workforce is vital to health care reform. That was the message delivered by AAFP President Ted Epperly, M.D., of Boise, Idaho, during his testimony before the House Ways and Means Committee on June 24 and a House Energy and Commerce health care subcommittee on June 25.

"Achieving quality, affordable health care coverage for all will require a significant investment in the health care system," said Epperly before the Ways and Means Committee. "However, simply paying for more of the same fragmented, uncoordinated, procedure-based health care will not make us healthier and will not begin to control health care costs."

"Primary care is the only form of health delivery charged with the long-term care of the whole person and has the most effect on health care outcomes," Epperly told the Energy and Commerce health care subcommittee.

"Many studies demonstrate that primary care is high quality and cost-effective because it includes coordination of health care services," he added.

The three committees in the House responsible for drafting health care reform legislation -- Ways and Means, Energy and Commerce, and Education and Labor -- released an 852-page draft of a health care reform bill on June 19. That bill, said Epperly, "goes a long way toward providing quality, affordable health care coverage for everyone in the United States."

"This is a change the AAFP has supported for two decades," he said.

The draft legislation includes a 5 percent bonus for primary care services and as much as a 10 percent bonus for primary care services provided in a health professional shortage area. The payments would be provided for services to ensure "accessible, continuous and comprehensive care." Moreover, the draft legislation specifies that to qualify for the bonus, at least 50 percent of a physician's services must be primary care.

"We estimate that 68 percent of family physicians would qualify," Epperly said.

But to ensure that the primary care bonus is received only by physicians who provide coordinated and comprehensive care, Congress should consider granting "deemed status" to certain specialties, such as family medicine, that are, by definition, primary care, he said.

The draft bill also would eliminate the sustainable growth rate, or SGR, formula, which has triggered steep reductions in the physician payment rate during the past several years. Congress has intervened previously to block the reductions, but physicians are facing a 21.5 percent payment reduction by the end of this year under the SGR unless Congress acts again.

"The Academy is gratified to note the bold, appropriate steps in the draft to remedy the flawed and dysfunctional formula known as the SGR," Epperly told the Ways and Means Committee. "Medicare is a critical component of the U.S. health system and must be stable and predictable for patients and providers."

He also praised the draft bill's inclusion of a medical home pilot program in Medicare as a step toward a primary care system. "Your definition of the patient-centered medical home is consistent with the one established by the AAFP and other primary care organizations," he said.

Epperly also lauded the bill's attention to workforce issues.

Primary care is in a crisis because of skewed payment systems that favor subspecialties over primary care, said Epperly. This discourages medical school students from pursuing careers in primary care medicine; payment reform will help address the issue, he added.

Rep. Jim McDermott, D-Wash., a member of the Ways and Means Committee, noted that he is sponsoring a bill (at the THOMAS Web site, type "H.R. 1411" in the search box after selecting "Bill Number") that will provide free tuition to medical students who attend state medical schools if they agree to practice as primary care physicians for four years.

"I very much support your thought in terms of looking at scholarships or loan repayments to try and create a workforce for primary care physicians," said Epperly. "I think there is a lot of merit in that."

McDermott and Epperly both agreed that it would be better to provide loan repayment programs for medical students when they start medical school, as opposed to providing such programs after they leave medical school.

Epperly also told the Ways and Means Committee that 98.9 percent of medical school graduates who go into family medicine stay in family medicine. The same is not true for internal medicine and pediatrics, according to Epperly. "In internal medicine, 98 percent (of graduating students) subspecialize," Epperly said. "In pediatrics, 85 percent (of graduating students) subspecialize. That's why we are facing such a crisis in primary care."