Payment Systems Fail to Recognize Long-Term Effects of Primary Care, Says Graham Center Director

May 12, 2010 10:55 am James Arvantes Washington –

Physician payment systems need to do a better job of recognizing and rewarding the long-term value of primary care services, especially as the newly enacted health care reform legislation begins to transform the U.S. health care system. That was one of the messages delivered by Robert Phillips, M.D., M.S.P.H., director of the AAFP's Robert Graham Center, who spoke on reinventing primary care during a May 4 forum here.

"The value of primary care is so distant from when it happens that we don't see it," Phillips told more than 300 physicians and other health care professionals during the forum, which was sponsored by Health Affairs.

For example, a primary care physician could work with a patient to reduce the patient's hypertension, but the results of that intervention may not become apparent for many years. It is not like removing a tumor or putting a stent in a patient's artery, Phillips said.

The failure to adequately invest in primary care has dire consequences, he said, pointing out that the United States spends twice as much as any other country on health care but is ranked 37th in the world in terms of overall health system performance.

"If you add in adjustments for disability and life expectancy, we fall to 72 in the world," said Phillips. "That is fundamentally because of our problem of not understanding what primary care is and not implementing it."

Phillips further outlined the importance of primary care in a May Health Affairs article(content.healthaffairs.org) he co-wrote with Andrew Bazemore, M.D., M.P.H., the assistant director of the Robert Graham Center.

The article provides a brief history of primary care in the United States and in other countries, and it analyzes how primary care became foundational to other health care systems in the world but not in the United States.

According to the article, approximately 240,000 primary care physicians represented 35 percent of the U.S. physician workforce in direct patient care in 2008. However, this proportion has been in decline, largely as a result of the enormous disparities in income between primary care and other specialties during the past two decades.

HHS Secretary Vows to Push For Medicare Payment Formula Adjustments

According to HHS Secretary Kathleen Seblius, the Obama administration will continue to push for adjustments in the Medicare physician payment formula to better reward the provision of primary care services.

Sebelius, who spoke during a primary care forum in Washington on May 4, said, "The reimbursement system clearly has penalized primary care providers over the last several decades." But, she noted, the Medicare and Medicaid programs present an "enormous opportunity" for realigning physician payment formulas.

The recent nomination of Donald Berwick, M.D., M.P.P., to head CMS is "another step in the direction" of readjusting payment, according to Sebelius. Berwick is known for his work on quality and cost initiatives, and, as a pediatrician, he is well aware of the need for an adequate primary care physician workforce, she said.

"These trends have now become so pronounced that it is likely that the primary care physician workforce will not replace itself over the next 20 years," said Phillips and Bazemore in the article.

Nevertheless, primary care remains the largest platform of formal health care in the United States. In 2006, 568 million visits were made to primary care physicians, accounting for 57 percent of all patient visits. Despite the volume of care, however, primary care visits are estimated to account for only 6 percent to 7 percent of total health care spending for Medicare beneficiaries, a percentage that may be even lower for patients in the private sector.

In their article, Phillips and Bazemore also stressed the inherent benefits of primary care, pointing out that "multiple investigators from various disciplines have assessed the effects of primary care and found that when people have access to primary care, treatment occurs before more severe problems can develop."

"People who receive primary care also have fewer preventable emergency department visits and hospital admissions than those who don't," said Phillips and Bazemore.

In addition, primary care clinicians use fewer tests, spend less money and protect people from overtreatment more than subspecialists do when providing routine care, according to the article.

Phillips and Bazemore acknowledged that primary care is not the "solution to every health-related problem. But few, if any, health-related problems can be adequately addressed without it."