Primary Care Key Component of Health Care Reform

The emergence of primary care as a central part of the health care reform debate demonstrates just how far primary care has come during the past several years in driving and shaping health care policy, according to physician leaders and health policy analysts interviewed by AAFP News Now.

"Primary care, 15 years ago, was nowhere near as respected or valued as it is now," says AAFP President Ted Epperly, M.D., of Boise, Idaho. "(Primary care) was clearly understood to be important to the health of people, but the central primacy of its role in regard to integration, coordination and comprehensiveness of care and the value of the patient/physician relationship as being at the epicenter of health care, was not as well understood."

During the past few years, however, primary care and the patient-centered medical home, or PCMH, have become synonymous with fundamental and systematic health care reform, which is required to achieve improved quality, enhanced access and lower costs, according to analysts.

The AAFP and other primary care organizations have been able to harness and apply this information to make a strong case on Capitol Hill about the need for a robust primary care system. And these efforts have helped push primary care to the forefront of the health care reform debate.

"I don't know of any (congressional member) who disputes the centrality of primary care and coordinated care and, therefore, the medical home," says Len Nichols, Ph.D., director of the health care policy program for the New America Foundation, a bipartisan think tank in Washington. "There are lots of different ways to think about how to fund it, lots of different ways to think about payment structure and lots of different ways to think about how to coordinate care." But in the final analysis, he adds, the concepts of nurturing primary care and encouraging coordinated care are "definitely front and center."

Nichols' sentiments are reflected in health care reform bills in the House and Senate. Such legislation may serve as the best example of how important primary care has become to the health care reform effort.

In the House, the three committees responsible for drafting health care reform legislation -- Energy and Commerce, Ways and Means, and Education and Labor -- have approved a so-called tricommittee bill (at the THOMAS Web site, type "H.R. 3200" in the search box after selecting "Bill Number") that calls for increased payments for primary care services. In the Senate, the Health, Education, Labor and Pensions, or HELP, Committee has passed a bill that also would increase payments for primary care services.

At the same time, the House and Senate legislation would provide funding to states to create community health team pilots that would work with small and mid-sized physician practices to create PCMHs.

"For the first time, physician practices in Medicare would have the ability to not only write a care plan but to make sure it is fully executed by having an interdisciplinary team work with them," says Ken Thorpe, Ph.D., executive director of the Partnership to Fight Chronic Disease and executive director of the Emory Institute for Advanced Policy Solutions in Atlanta.

The medical home pilots contained in the legislation represent "fully accountable payments with a twist," according to Nichols -- a way of changing the current physician payment structure to reward primary care physicians for achieving quality standards while managing resources in a more effective way. In the process, the pilot projects, if enacted, will help create systematic and sustained reform based on primary care and the PCMH.

"The core idea is to expand everyone's access to appropriately coordinated care, with the primary care clinician as the quarterback or the center of the team," says Nichols.

Thorpe is convinced that primary care will become even more important as the nation grapples with increasing rates of chronic disease and illness.

"Just go to the numbers," says Thorpe. "Three-quarters of national health care spending is associated with people who have one or more chronic health conditions." Moreover, chronic diseases account for more than 95 percent of spending in the Medicare fee-for-service program, he adds. "If we want to get to the cost issues, we have to do a better job of averting disease in the first place by targeting obesity and smoking and other behavioral risk factors."

He describes primary care as a "centerpiece for more effective management for patients with multiple chronic health conditions."

One of the major challenges is to prevent unnecessary hospitalizations and hospital readmissions -- a perfect role for primary care and the PCMH, according to Thorpe. "Medicare patients have high rates of preventable hospitalizations," he says. "Twenty percent of Medicare patients are readmitted to the hospital within 30 days.

"More effective primary care could cut those rates in half."

Not surprisingly, Thorpe and others have called for a health care system that better integrates primary care.

"We have to reorient our system toward primary care," says Barbara Starfield, M.D., M.P.H., a university distinguished professor of health policy at Johns Hopkins University, Baltimore, who has written extensively about the importance of primary care during the past 15 years. "And that means training more primary care physicians and not letting specialty-oriented societies decide policy."

Such a reorientation would require better payment rates for primary care physicians along with incentives for "good primary care practice," says Starfield.

The House and Senate health care reform bills address the need to strengthen the primary care workforce. In the Senate, for example, the HELP bill would establish a national health care workforce commission to determine current and projected workforce needs and to advise Congress and the administration on how to align workforce resources with national needs. The bill also includes funds for family physician training and other primary care specialty training.

"The AAFP has been, in my view, the leader in taking the message to (congressional) members and the policy community about the extreme crisis in primary care practice and the shortage of people going into primary care," says Nichols. "The AAFP has identified the crisis, and (it has) very much defined the solution."

If done properly, health care reform "will make the profession of primary care far more attractive to go into," he adds. "It will make (family medicine) more remunerative, as well as more professionally satisfying."