Primary Care America's Health in a New Era (1996) / Chapter Skim
Currently Skimming:
The Value of Primary Care
The Value of Primary Care
Pages 52-75
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From page 52... ...
If the health care system is to move in the directions identified in this report, the value of primary care must be clear to the American public, policymakers, communities, educators, individual health professionals, and students. All people adults as well as children, middle-class as well as poor, the healthy as well as the ill must be seen to benefit.
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From page 53... ...
Addressing Most Problems That Patients Bring Most of the problems that people bring to the health care system are appropriately resolved at the level of primary care. Having the capacity to address "a large majority of personal health care needs" also means that primary care offers patients a sensible and convenient route to appropriate care, which may involve referrals or coordination of services by others; patients do not need to guess for themselves what is causing a symptom or concern to be able to enter the health care system at the right place.
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From page 54... ...
These vignettes illustrate that in addressing the "large majority of health needs" the primary care clinician and the patient benefit from the characteristics of primary care, including integration, the development of a sustained partnership, and attention to the context of family and community. Guiding Patients in Using the Health Care System A major element of good primary care is the ability of primary care clinicians to diagnose and manage their patients' health care problems.
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From page 55... ...
Primary care clinicians who know how the health system operates and have the expertise to evaluate information can provide instructions that patients can understand and help patients and families to make appropriate decisions and use the health care system to best advantage. In pediatrics, this concept is known as a "medical home";2 it is an appealing concept for all ages.
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From page 56... ...
Some problems are clearly related one to another; some are not clearly related but, when concurrent, may influence each other. Over the years, primary care clinicians will see patients through waves of episodes of care some spells of illness and treatment stop, others begin, and others overlap.
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From page 57... ...
57 Time in effect an element of continuity is an excellent diagnostic tool. Because of ongoing relationships with patients, primary care clinicians can better evaluate the importance of a patient's symptoms than can practitioners who do not know the patient.
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From page 58... ...
. The benefits include earlier and less onerous health care interventions, better and less hurried decisionmaking between the primary care clinicians and patients and their families, and likely lower costs of an episode of care.
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From page 59... ...
Bridging Personal Health Care, Family, and Community 59 Primary care clinicians can establish links with communities and their resources, including those that patients on their own may not be aware of or be able to gain access to. In this way, they can create valuable bridges between what is done to and for patients and their families within the personal health care system and the preventive health or social services that may be available in the area in which patients reside.
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From page 60... ...
A primary care team can work closely with older persons and their families (or close friends or members of other social support systems, such as churches) to sustain these connections between personal health care services and long-term-care and social services.
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From page 61... ...
The primary care clinician can also be an effective advocate in the community for needed public health actions. Good examples are the successes pediatricians have had in advancing child health through community actions, e.g., lead abatement, child safety seats, safety caps on medicines, community awareness of child abuse, support of poison control centers, and immunization campaigns.
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From page 62... ...
In posing these illustrative scenarios, the committee wishes to draw attention not only to the promise of primary care in pulling these threads together on behalf of the patient but also to the obstacles that opposing trends in health care delivery can place in the path of realizing that promise. PRIMARY CARE AND COSTS, ACCESS, AND QUALITY Empirical research, though sometimes indirect, indicates that primary care reduces costs, increases access to appropriate medical services for the population being served, and does not reduce the quality of care, thereby advancing the broader social interests in health care.
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From page 63... ...
Costs of Care The primary care model is widely believed to be less expensive than specialty medicine, in part because payments to primary care clinicians are lower and in part because primary care clinicians tend to use fewer resources than other specialists. Several studies suggest that primary care physicians tend to deliver less intensive care than specialists, particularly in hospital settings.
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From page 64... ...
Overall, there was a 15 percent decrease in costs for the group enrolled in the primary care physician program as compared to usual costs in the Medicaid program in which patients did not have access to a usual primary care physician. Evidence demonstrating that primary care providers are more efficient in their use of resources has led managed care organizations to use "networks" of primary care physicians.
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From page 65... ...
The concept is relevant to primary, specialty, and even exotic or experimental care, but in all cases, access to appropriate care is influenced by the number and distribution of primary care clinicians. To cite cases in point, when individuals do not have a usual source of primary care because of geographic, financial, or other barriers, the care they receive through emergency departments may be both costly and inefficient (Shea et al., 1992~.
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From page 66... ...
Patients who were assigned to a primary care physician had substantially fewer emergency department visits without an accompanying increase in office visits to a primary care physician. With respect to hospital admissions, Parchman and Culler (1994)
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From page 67... ...
Shi (1992) showed a consistent relationship between the availability of primary care physicians and positive health status in 50 states and the District of Columbia, as assessed by age-adjusted and standardized overall mortality, mortality associated with cancer and heart disease, neonatal mortality, and life expectancy; the association held even after controlling for the effect of urban-rural differences, poverty rates, education, and lifestyle factors.
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From page 68... ...
They reported a 38 percent decrease in emergency department visits by center-area children from 1967 to 1970. For routine care of these children, the primary care setting can be presumed to be more appropriate and less expensive than alternative settings, such as emergency departments or hospitals.
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From page 69... ...
Starfield and others have reviewed research evidence that continuity of care is "associated with more indicated preventive care, better identification of patients' psychosocial problems, fewer emergency hospitalizations, fewer hospitalizations in general, shorter lengths of stay, better compliance with appointments and taking of medications, and more timely care for problems" (Starfield, 1986, p.
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From page 70... ...
Most managed care plans insist that the primary care clinician be the pathway to specialty care. Some empirical work supports this principle in terms of its effect on quality.
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From page 71... ...
She depicted her primary care services as "a cup bobbing on a sea of social problems." High levels of teenage pregnancy, perinatal mortality, substance abuse, or occupational illness all signal factors far beyond the capacity of individual health care or even health promotion and disease prevention programs to cope with successfully. Primary care clinicians do, however, form an important bridge between the health and public health realms that is, between personal and population health services.
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From page 72... ...
The vignettes in this chapter illustrate that pnmary care provides a place to which patients can bring a wide range of health problems for appropriate attention; guides patients through the health system; facilitates an ongoing relationship between patients and clinicians in which patients participate in decision making about their health and their own care; provides opportunities for disease prevention and health promotion as well as early detection of problems; and helps build bridges between clinicians and patients' families and communities. Empincal research also indicates the meets of pnmary care as a means of improving the overall performance of the health care system, by improving the quality and efficiency of care and expanding access to care.
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From page 73... ...
Greenfield, S., Nelson, E.C., Zubkoff, M., et al. Variations in Resource Utilization Among Medical Specialties and Systems of Care: Results from the Medical Outcomes Study.
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From page 74... ...
Effect of the Neighborhood Health Center on the Use of Pediatric Emergency Departments in Rochester, New York. New England Journal of Medicine 285: 148- 152, 1971.
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From page 75... ...
Primary Care Performance in Fee-for-Service and Prepaid Health Care Systems. Results from the Medical Outcomes Study.
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