Criticism by Emergency Physician Misses Mark

A recent opinion piece by Jonathan Glauser, M.D., M.B.A., in the December issue of Emergency Medicine News created a loud outcry of "foul" from primary care physicians around the country.

Glauser's column, titled "The Disgraceful State of Primary Care," took direct aim at primary care physicians with little regard for the overwhelming data that shows how vital primary care is as the foundation for effective and quality patient care.

Family physicians were vocal in their disdain for Glauser's viewpoint, and they were joined in that position by their primary care colleagues at the American College of Physicians and the American Osteopathic Association.

In response, I, along with my contemporaries at the ACP and the AOA, wrote letters to Emergency Medicine News. Following is the text of the letter that I wrote.

In his column, "The Disgraceful State of Primary Care," Jonathan Glauser raised a number of issues about the U.S. health care system. But it is the system, not primary care, that has fallen into disgrace.

This is a system that pays for procedures, rather than medical expertise, and results in financial, geographic and time barriers to health care for the underinsured, the uninsured, and those who live in geographically underserved areas.

But the solution is not to discredit primary medical care, which -- according to research dating to the 1990s -- undergirds all high-functioning health care systems in the world. Instead, the solution is to rebuild primary care in the United States so that doctors have the time to be doctors and patients receive the right care at the right time in the right place. And the best vehicle for rebuilding the U.S. health care system is the patient-centered medical home.

The patient-centered medical home is a concept of care, not a payment system. The medical home is a medical practice that gives patients a personal physician who works with a team of health professionals to care for the patient. That care is coordinated across all elements of the health care system, including subspecialist care, hospitalization, home health agencies and community services. The medical home professional uses information technology to exchange health information with pertinent colleagues and institutions, to establish registries, and to design office practices to ensure open-access scheduling, extended office hours and convenient online communication with patients. As a system of care, the medical home can provide health services to patients regardless of their insurance status or ability to pay.

Family medicine -- the only specialty that focuses only on primary care -- trains physicians in virtually all areas of medicine. Family medicine residents complete rotations on all hospital units, including surgery, inpatient care and maternity care. As a result, family physicians have the medical expertise to provide several levels of care themselves and to know when a patient requires subspecialist attention. The 2008 survey of American Academy of Family Physicians members reported that 77 percent see patients in the hospital, 38 percent see patients in coronary care units, 45 percent see patients in intensive care units, 40 percent provide emergency room care, and 30 percent do surgery, in addition to their office practices.

These services are particularly valued in geographical health professions shortage areas, where family physicians are the only source of medical care for millions of Americans. The AAFP survey reported that 77.5 percent of respondents provide care in rural areas. Moreover, respondents reported providing free care to an average of 9.5 patients per week. One of every 10 of survey respondents' patients had no health insurance.

It is this commitment to ensuring that patients have access to comprehensive care that makes primary care uniquely capable of improving health care outcomes, reducing disparities in health care among underserved populations and controlling health care costs.

This has been demonstrated repeatedly in studies by researchers ranging from Johns Hopkins University's Barbara Starfield, M.D., M.P.H., to the Commonwealth Fund's Commission on a High Performance Health System. Pilot programs such as North Carolina's Community Care program for Medicaid patient demonstrate the success of the primary care, patient-centered medical home in caring for low-income patients. Projects such as IBM's patient-centered primary care initiative with Pennsylvania's Geisinger Health System prove that a patient-centered medical home can improve outcomes and rein in costs. Throughout the country, private insurers, state governments and health systems themselves are testing this concept and, to date, determining that the medical home improves patient access to care, the quality of care, outcomes of care and cost control.

The uniform outcomes of these pilot projects demonstrate that the concept of a primary care, patient-centered medical home does, in fact, work to the benefit of all stakeholders. Family physicians and their primary care colleagues are proud to move beyond pointing out the serious flaws of America's health care system and, instead, help lead the movement that is helping to solve the very problems cited by Dr. Glauser.