Sunday, January 17, 2016
Are primary care practices prepared for complex patients? Is this even the right question?
The goal for our national policy should be that every person have the best health status that they can. One component of this, although certainly not all of it, is access to high-quality appropriate health care services. This means that people can receive the care that they need, when they need it, and do not receive unnecessary or harmful care. Access includes both financial and physical (geographic) access, and also access to high-quality care (see, for example, "Et qui vendit pellucidum", a recent blog post by my friend Dr. Allen Perkins).
One part of having access is that there need to be sufficient numbers of providers, appropriately trained and distributed to meet those health needs. It also means that those providers should have no reason or incentive to preferentially provide certain types of care rather than others, or care to certain people rather than others. Unfortunately, the profit motive skews this in the US; we have redundancy of profitable services like “cancer centers” and “heart centers” in major metropolitan areas, with hospitals competing for the same pool of patients, while in other areas even primary care is unavailable. We have excess capacity in some areas (every hospital, for example, needs an MRI or patients might go somewhere else, even if the number of MRI scans the population needs doesn’t justify it; providers prefer to take care of less-complex patients – a single joint replacement in an otherwise-healthy 45 year old with an athletic injury is more profitable than, and thus preferable to, doing a joint replacement in an 80 year old with multiple medical problems).
A recent survey of primary care providers in 10 countries by the by Robin Osborn and colleagues from the Commonwealth Fund, “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”, published in the December 2015 issue of Health Affairs (only the abstract is available free on line) sought to determine whether primary care physicians (there are, at least in the US, other providers like NPs and PAs who are not physicians) feel competent to provide various types of care. The 10 countries were all wealthy and highly developed (Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States). All but the US have some form of universal health care, although the way that it is organized (e.g., single-payer government health insurance in Canada, a national health service in the UK, multiple non-profit insurers in several others) varies from country to country. In most countries, “primary care” meant family physicians or GPs, but in others (including the US), it also included general internists and general pediatricians.
The researchers found both similarities and differences by country in the percent of primary care practices that had confidence in their ability to adequately address population health needs, especially those that are increasing because of the aging of the population. For example, the confidence of these practices in managing patients with multiple chronic conditions was generally high (from 70% in Canada to 88% in Germany and the Netherlands; the US was at 76%). Fewer practices were confident in other areas, and there was greater variance. For example, 92% of practices in the Netherlands and 81% in the UK had high confidence in providing palliative care, while Sweden (25%), the US (41%), and Canada (42%) were much lower. Similar variations existed for other services (see table); for example, confidence in dealing with patients with substance use related issues were much lower (from 16% in the US to 41% in the UK).
The authors also surveyed whether practices had a number of characteristics that many experts think are important for being able to effectively and efficiently manage complex patients. These included use of electronic health records (European countries were ahead, but the US and Canada, late adopters, are catching up), team based care, after hours care not requiring visiting the ER (the US is very low), access of patients to their medical records (the US is very high as this is one of the criteria for “meaningful use” payments from the federal government), communication between different hospitals, specialists, and ERs with the primary providers (all over the board including in the US), and many other areas.
Of course, these surveys reflect the experiences of physicians in different countries, and are thus subjective rather than compared to some iconic “gold standard”. People do not know what they do not know, or haven’t experienced, or cannot even imagine; their experiences are context-dependent, and so cannot be directly compared. For example, the survey asked whether physicians thought that (their) “system works well; only minor changes needed”. Only 16% of US doctors answered positively, with the high being in Norway, 67%. However, in the UK the number was also very low – 22%. How can we interpret that? In all of these countries, save the US, including the UK, everyone is covered. 78% of UK physicians may not believe that their “system works well; only minor changes needed”, but what would they think if the alternative was a non-system like the US where there are large numbers of uninsured people? Would they think that a better system? Probably not, but can’t tell from this data.
Finally, and perhaps most important, the survey does not look at whether there are a sufficient number and appropriate distribution of primary care providers to meet a country’s needs even when the practices are well-organized. It is my impression that the answer to this question is closer to “enough” in most of these other countries; I am certain it is not in the US. In our country, the financial rewards for subspecialization and the “lifestyle” (and sometimes financial) rewards for urban location are major determinants in our distribution of providers across specialties and geography. There are far too few primary care providers as a percentage of all physicians, and while family physicians are far more equitably distributed than other specialists, there are still big geographic disparities. Among the many “solutions” that have been suggested, I believe that only one will work: eliminate, or at least dramatically decrease, the income differential between primary care and subspecialties. This is not as far-fetched as it seems; as I have discussed before, high income for some specialists and procedures are not market-drive but are set by policy; Medicare sets these rates.
As far as geographic disparity is concerned, this is an issue that most effects primary care and a few other specialties (psychiatry, general surgery) since most subspecialists practice only in urban areas where there are sufficient populations to use their services. This also can be addressed by money: pay providers differentially more for more rural practice. We also need to provide financial resources to support these practices not only for income, but for wrap-around care. Support must be provided to these practices so that they can afford the capacity to care for the complex problems addressed in the survey.
A general practitioner from Denmark (not one of the 10 countries surveyed) told me about how his anesthesiologist son-in-law really liked his work. I chuckled about how much he must make. He told me no, actually in Denmark GPs make more. This is a good illustration of how our assumptions are context bound.
It is also the way we need to go in the US.
 Osborn R, Moulds D, Schneider EC, et al., “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”, Health Affairs 34, no.12 (2015):2104-2112, doi: 10.1377/hlthaff.2015.1018