Primary Care On the Ropes (Chapter 4)

Jeffrey Kagan, MD, a general internist in Newington, Conn., recalls an elderly patient who came to his office and complained about a burning sensation when he urinated. He also had a little back pain and fever. Kagan quickly determined that the person had a urinary tract infection. His heart rate was 95 and his blood pressure was 110/70, but the internist didn’t think that was any cause for concern. The doctor prescribed an antibiotic and sent the patient home, instructing him to drink a lot of fluids. In a few days, the patient felt much better.

“If the same person had gone to the ER,” Kagan says, “he would have been told, ‘You have a urinary tract infection with sepsis. We know you have sepsis because your heart’s a little fast and your blood pressure is a little low. You must be admitted to the hospital and get IV fluids and IV antibiotics.’ I see this all the time.”

If an older person visits the ER complaining of a bellyache in his or her side, “they get a CT scan and are told they have diverticulitis,” notes Kagan. “They probably get admitted to the surgical service. They get put on IV antibiotics and are kept without food. Then the surgeon comes by and says, ‘We’re going to let things cool off for a few weeks and then you’re going to come back and we’re going to cut out your diverticulitis.’ 

“If they wander into my office with a pain in the side, I say, ‘We’re going to send you for a blood test and for a CT scan today. This afternoon, you’ll come back to the office and we’ll go over it. If you have diverticulitis, we’re going to tell you to go on a clear liquid diet, and we’re going to give you these two oral antibiotics, and we’ll see you again in a week. Of course, if things get worse, you’ll talk to us sooner. Then we’ll see you again in a few weeks.’ So this person avoids the hospital and, guess what, they don’t have surgery.”

Kagan will recommend surgery, he says, if the patient has three episodes of pain from the diverticulitis; but only about 25% of patients with diverticulitis need an operation. Generally, they can control the condition if they avoid eating seeds and stick to a high-fiber diet, he says.

Sometimes a patient just needs a little understanding from their primary care physician to avoid a bad outcome. Kenneth Kubitschek, MD, an internist in Asheville, N.C., recounts a story about an 86-year-old patient who, at his family’s suggestion, self-referred himself to a neurologist for a persistent headache. This patient had a history of lung cancer, and it was possible that the cancer had metastasized to his brain. A CT scan showed that he indeed had a mass on his brain, and the neurologist referred him to a neurosurgeon. After discussing the options, the surgeon recommended removing the mass, the man agreed, and he was scheduled for surgery.

But the patient was uneasy about his decision, so he went to see Kubitschek, who had been his primary care doctor for 30 years. Kubitschek asked him what he really wanted, and the patient said he’d prefer to stay at home and die there. It turned out that he’d consented to the procedure mainly because he wanted to please the surgeon. So Kubitschek sat down with the elderly man and his family for an hour, and they eventually decided to cancel the surgery, call in hospice treatment, and hire home health aides to help his family care for him. The doctor recalls that his patient was “very happy with that decision,” and he died comfortably at home a couple of weeks later.

“Without primary care being involved, I think he would have gone down a different path,” Kubitschek says. “Surgery probably would have been very damaging to a man of his age. Even if he’d survived it, he probably wouldn’t have survived it well. And given that the cancer was metastatic…I just wanted to find out what he wanted, and sometimes that’s what primary care’s goal is.”

What these stories show is that patients who receive good primary care from a trusted personal physician usually have better outcomes and cost the system less money than those who have no regular source of primary care. This is not news to most healthcare professionals; but unfortunately, many Americans don’t have a primary care physician. They get their healthcare from walk-in clinics, ERs, and/or specialists.

What the Evidence Shows

Many other countries’ healthcare systems outperform ours for one simple reason: They place a much greater emphasis on primary care, which occupies the central place in their systems. “The evidence is that where you have more primary care physicians, where you coordinate care, and where you pay to keep people healthy, you get better outcomes at lower cost,” says David Nash, MD, founding dean of the College of Population Health, part of Thomas Jefferson University in Philadelphia.

The evidence that Nash mentions includes studies by Barbara Starfield and her colleagues at Johns Hopkins University. In a 2005 Health Affairs paper, they showed that a higher ratio of primary care physicians to the population is associated with a lower mortality rate from all causes and from heart disease and cancer; in contrast, having more specialists in a particular area does not decrease the overall mortality rate or deaths from cancer and heart disease.1

Another study of Medicare data found that states where a higher percentage of physicians were PCPs had higher quality care and lower cost per beneficiary. This factor alone accounted for nearly half of the variation in Medicare spending from one state to another.2 A separate study found that in the areas of the country that had the most primary care providers, the average Medicare cost per beneficiary was a third lower than in areas with the least PCPs.3

One reason for this is that primary care doctors provide comprehensive, continuous care, including preventive and routine chronic care. Chronic illnesses drive 90% of health costs, and some studies show that intensive primary care can reduce ER visits and hospital admissions and improve the health of chronically ill people.4

In addition, primary care physicians strive to understand the whole patient, both physically and mentally. Besides having an in-depth knowledge of each patient’s health factors, “I know what’s going on in their lives,” Kagan says. “I know who’s getting divorced and who’s lost their job and who has some stress in their life.”

This comprehensiveness is an essential feature of primary care. “We don’t miss an opportunity to fix the things that down the road are going to be significantly greater problems for you,” says Russell Kohl, MD, an official of the American Academy of Family Physicians (AAFP). “That’s the challenge we have around a specialty-driven approach, where patients say, ‘let me see a bone doctor for my bone problem or a heart doctor for my heart problem, or a kidney doctor for my kidney problem,’ and not see those three things are integrally connected with each other. It’s that comprehensive approach that makes sense for you long term.”

A “Sick” System

Not all primary care physicians provide this level of holistic care. But in general, primary care is oriented to keeping people healthy as well as treating them when they’re sick. And primary care is “upstream” of the more costly, specialized care that may be required when people get really ill.

Overall, Nash notes, the U.S. healthcare system is designed to treat sickness, not to maintain health. “If we had a focus on going upstream and shutting off the faucet rather than mopping up the floor, primary care would have a central role,” he says. “But the system is focused all downstream, which reduces the prestige of primary care physicians and the range of skills that they need. If the system were focused upstream, they’d be paramount.”

The difference in how primary care physicians are regarded in the United States and in other nations is reflected in the amount of resources devoted to them. In this country, one study finds, only 7% of the total cost of care goes to primary care (other studies estimate it at 5%). In contrast, around 20% of healthcare spending in other advanced countries is allocated to primary care.5 The ratio of specialists to primary care doctors in the United States is about 2:1. In other countries, the ratio is about 50/50.6

Since these other nations rely much more heavily on primary care than we do, their systems are organized differently from ours. So, if we want to achieve results similar to theirs, we should restructure our system to emphasize primary care. However, the indicators for U.S. primary care are moving in the opposite direction. 

  1. Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations’ health: Assessing the evidence. Health Aff. 2005 Jan-Jun; Suppl Web Exclusives: W5-97-107. 
    https://doi.org/10.1377/hlthaff.w5.97. 
  2. Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Aff. 2004 Jan-Jun;Suppl Web Exclusives: W4-184.97. 
    https://doi.org/10.1377/hlthaff.w4.184.
  3. Fine MD. Presentation, Society of Primary Care Policy Fellows. March 26, 2009. Archived by Robert Graham Center. https://www.graham-center.org/content/dam/rgc/documents/publications-reports/presentations/universal-primary-care.pdf.
  4. Lazris A, Roth A, Brownlee S. No more lip service; It’s time we fixed primary care (part one). Health Affairs (blog).Nov. 20, 2018. https://www.healthaffairs.org/do/10.1377/hblog20181115.750150/full/.
  5. Goroll AH. Does primary care add sufficient value to deserve better funding? JAMA Intern Med. 2019;179(3):372-73. doi:10.1001/jamainternmed.2018.6707. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2721034.
  6. Nash D. Pondering the primary care predicament. MedPage Today. May 16, 2019. https://www.medpagetoday.com/columns/focusonpolicy/79883?xid=nl_mpt_DHE_2019-05-17&eun=g1342670d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%2014%20day%202019-05-17&utm_term=NL_Daily_DHE_14signups