A new study in JAMA Internal Medicine adds weight to the importance of primary care, but says lack of value-based investment is preventing it from fulfilling its promise. The researchers compared U.S. adults with and without primary care from 2012 to 2014 on 39 clinical quality measures and seven patient experience measures. The results were aggregated into 10 clinical quality composites. Those receiving primary care were found to have received significantly more high-value care, slightly more low-value care and better overall experiences than those without primary care.
Researchers found no notable difference in volume of outpatient, emergency room and inpatients for patients with primary care and those without. However, those with primary care filled more prescriptions and were more likely to have had a routine preventive visit in the past year.
The researchers—David M. Levine, M.D., M.P.H., Brace E Landon, M.D., MSc., and Jeffrey A. Linder, M.D., M.P.H., wrote in their article, “Quality and Experience of Outpatient Care in the United States for Adults With or Without Primary Care,” “Receipt of primary care was associated with significantly more high-value care, slightly more low-value care, and better health care experience. Policymakers and health system leaders seeking to improve value should consider increasing investments in primary care.”
In setting a frame around their study, Drs. Levine, Landon, and Linder, note that, while “many countries made primary care the foundation of their health systems, by contrast, the U.S. healthcare system is generally organized around hospitals and specialty care, despite landmark reports, such as the 1966 Millis Commission Report, recommending that each person have a primary care physician.”
The researchers used a complex, nuanced methodology in order to parse and analyze their data. What they found, essentially, was that “Respondents with primary care received more high-value care compared with those without primary care in 4 of 5 composites. Approximately 78 percent of respondents with primary care received high-value cancer screening compared with 67 percent without primary care. The largest differences,” they wrote, were for colorectal cancer and mammography screening. “Respondents with primary care also received more recommended diagnostic and preventive testing,” they noted.
The researchers did find a few anomalies. For example, they wrote, “For the relatively small number of patients with heart failure or pulmonary disease, respondents with primary care received less high-value care. For example, those with primary care received fewer β-blockers in heart failure, and fewer controller medications in poorly controlled asthma. Of those with primary care included in the β-blocker measure, 62 percent also were also seen by a cardiologist, and of those with primary care included in the asthma measure, 48 percent were also seen by a pulmonologist.”
In their Conclusion section, the researchers wrote, “In this large, nationally representative survey study, we quantified the potential benefit of primary care with respect to receipt of high- and low-value health services and experience with and access to care within the current health care delivery environment. We found that receipt of primary care was associated with more high-value care, somewhat more low-value care, and better respondent access and experience. Respondents without primary care, even though they were receiving a similar amount of care, missed substantial health care benefits: about 10 percent fewer went without high-value cancer screening, diagnostic and preventive testing, diabetes care, and counseling. Similarly, about 10 percent fewer respondents without primary care rated their overall care, physician communication, and access to care as excellent. These differences are noteworthy when considered in the context of mixed or flat improvements in quality during the last decade. To our knowledge, this is the first study to directly compare outpatient quality and experience when delivered inside or outside of a primary care relationship.”
Still, they wrote, “Primary care, however, was not uniformly associated with more high-value care. For instance, primary care was associated with worse care for heart failure and pulmonary disease, albeit with relatively small numbers of respondents without primary care qualifying for these measures (approximately 50 patients or fewer for both). Approximately half of patients with primary care who qualified for these measures also had visits with a relevant specialist. Prior research shows that, in general, specialists provide higher quality care in their area, but largely do not address issues outside of their specialty; thus, these findings should not be interpreted as suggesting that a specialty dominated model would be better. Care for patients with heart failure or pulmonary disease could potentially be improved with better primary-specialty care co-management, increased education of primary care physicians, or other interventions.”
