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Monday Dec 04, 2017

Primary Care Benefit Could Improve Outcomes, Lower Costs

We talk a lot in this country about health care. What do we mean by that? Do we mean insurance? Is it about getting help when you're sick? Is it about the quality or quantity of care you receive? What about prevention?

[ounce of prevention pound of cure signs]

When we talk about health care in the United States, too often we are really talking about sick care. Although we have the best sick care in the world, we are far behind the rest of the industrialized world in actual health care.(www.commonwealthfund.org)  

When you get sick or need care for a condition -- whether you have an infection, a surgical emergency, an injury from an accident or if you are pregnant -- the U.S. health care system does a good job, especially if you are insured. What we do not do as well is prevent illness and maintain health, especially among vulnerable populations. To me, that is health care, or care of your health.

Why is the track record so poor in this area? As with many issues, it is multifactorial. Components of the problem include nutrition, exercise, social determinants of health and, of course, preventive medicine. In addition, physicians have not been adequately compensated in the past for our work in prevention. It takes time to discuss nutrition, exercise and the need for interventions, but we typically are paid on a per-patient basis that limits our time in the exam room.

When I was in medical school, a preceptor of mine told his patients, "I do piecework." Most of his patients worked in clothing mills and were paid based on how many pieces they completed in a day. The analogy is a good one. As physicians, we have been paid based on the number of patients we see in a day. Although we are moving away from a volume-based system to one based on quality of care, time remains a limiting factor for many of us.

This stress on the system not only affects physicians, but also, ultimately, the patient. I constantly hear stories of how siloed care leaves the patient without any advocate. We have hospitalists taking care of admissions and subspecialists taking care of bits and pieces of the patient, but often there is not one physician following the patient through the entire process. On discharge, a massive volume of paperwork is sent to the primary care physician in the form of a discharge summary.

Although we can take care of your failing kidney and your diabetic foot ulcer -- in two different departments of the medical system -- preventing both of those complications is the type of health care we should be promoting. That is the job of the family physician, and we are good at it. So why aren't we paid accordingly?

Plan after plan has been offered in Washington as a fix for the broken health care system. None of these addresses health care. They all address sick care or insurance. We need to talk about a primary care benefit for all patients. It should not matter if someone has insurance or not, it should not matter if someone has money or not, it should not matter if someone has a job or not. The AAFP has been advocating in Washington for such a primary care benefit for those who are insured. For the poor and uninsured, the AAFP advocates for Medicaid expansion in the states.

All Americans deserve the opportunity to maintain their health with a primary care physician. If all Americans could have a family physician, they could more easily maintain their health, address the issues that affect their health and help prevent complications so we could drive down the cost of health care.

There will be changes in health care coming down the road. Let's see if we move toward real health care where we care for the health of our patients. We will still have sick care to help those who have not benefited from prevention, but we will save money in the long run by keeping everyone healthy instead of waiting until they get sick.

Leonard Reeves, M.D., is a member of the AAFP Board of Directors.

Posted at 08:51AM Dec 04, 2017 by Leonard Reeves, M.D.

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