Primary Care in Crisis

The "Primary Care is in Crisis" white paper series was produced in 2009 to provide MPCC members with information about the crisis in primary care and its contributing factors. Resolution of the crisis will require efforts in three arenas: transformation of the way primary care is delivered and compensated, activation of healthcare consumers, and rebuilding the primary care workforce. Parts 2-4 of the series contain specific recommendations for actions MPCC could take to address the crisis.

White Paper Series: Primary Care is in Crisis
Part 1: Primary Care is in Crisis
Part 2: Transform Primary Care Practice and Payment
Part 3: Activate Consumers of Primary Care
Part 4: Rebuild the Primary Care Workforce

Declining Primary Care Workforce

The primary healthcare system which is the foundation of the entire US healthcare system is in danger of collapse. There has been a steady decline in the number of physicians, nurse practitioners and physician assitants working in primary care. At the same time, the demand for primary care services is increasing as the baby boomer population reaches retirement age and needs chronic illness care. The demise of primary care will have serious and far reaching consequences. A vibrant primary care system is the best hope for improving health while controlling escalating healthcare costs.

Escalating Healthcare Costs, Unimpressive Indicators of Health

The US spends more per capita on healthcare than any other country in the world

Click graph for larger image

With such a large investment in health, it is reasonable to expect the US to lead the world on health outcomes. Instead, the US lags behind other developed nations on key indicators of health.

                                              US                  Best Ranking               Worst Ranking
      Health Indicator             No. Rank       Name     No. Rank      Name No.   Rank
Life Expectancy ( yrs)   78.1    49      Macau 84.5      1        Angola    38.2 224
Infant Mortality *            6.2 180        Singapore 2.3   224      Angola    180    1
Preventable Deaths* 99    19      France      21         1        US     99       19
*per 100,000 population

The Rand Corporations First National Scorecard on the quality of healthcare in the USA, reported that across the US, individuals receive only about half of the recommended chronic illness and preventive care.

What Can Be Done?

The crisis in the primary healthcare system can be resolved, and a high functioning system that better meets today's need for effective, efficient health care can be created. This will require simultaneous efforts in four areas where the status quo has created a faltering primary healthcare system.

1. Transform Primary Care Practices to Patient Centered Medical Homes.

Traditional primary care practices are designed to provide episodic care, such as annual physical exams and treament of acute illnesses. To meet the changing needs of the US population, a patient centered model of primary care, designed to provide ongoing, coordinated, whole person care throughout one's life, is needed. Patient centered medical homes (PCMH) are primary care practices that are equipped with electronic tools and that have been redesigned to provide comprehensive, coordinated patient centered services. These practices provide good acute care, but they also partner with patients to optimize wellness and achieve good management of chronic illnesses. To learn more about the patient centered medical home click here

2. Reform Primary Care Payment

The system that provides payment for healthcare services contains perverse incentives that weaken the primary care system and feed escalating healthcare costs. The system pays sub-specialists a higher hourly rate for doing procedures and diagnostic imaging than it pays primary care physicians to evaluate and treat sick patients. Since increases in primary care payment rates have been lower than inflation rates for several years, primary care physicians are pressured to increase the number of patients seen per day to make ends meet. As the gap between primary care and specialty care salaries widens, fewer and fewer medical students see primary care as an attractive career coice. Payment reform is needed to realign incentives so that instead of rewarding the volume of services provided, providers are rewarded for the value of their services. Patient centered medical homes provide valuable services that currently are compensated. Pilot PCMH demonstration projects are testing various payment models. See Part Two of the white paper series above. For additional information click here.

3. Engage Consumers in Their Own Healthcare

Most individuals spend relatively little time actually interacting with the healthcare system. In fact, medical treatment is considered to account for only 20% of an individual's health status. Other contributers to health are genetics, environment, and the continuous lifestyle choices individuals make day after day. In patient centered medical homes, individuals, (and when appropriate their family or caregivers), partner with a healthcare team to develop an individual plan for maximizing their health. The practice team provides different kinds of support for indivuals as they learn to become good managers of their health and illnesses. One such support is to link individuals to resources within the community for education and services that can meet physical, social, and mental health needs. For more information about Consumer Engagement click here.

4. Rebuild the Declining Workforce

The survival of primary care is threatend by the declining number of primary care physicians, nurse practitioners, and physician assistants working in primary care. For many years, there have not been enough new graduates entering primary care practice to replace those who are retiring or leaving practices to take other positions. This makes it difficult for individuals to find someone to provide routine health care, and often care is delayed under complications, or progression of illnesses has occured. Urgent action is needed to reverse this decline. For more information about the primary care workforce click here