August 21, 2012 — Nearly 40% of primary care services are provided by specialists, according to a research letter published online August 20 in the Archives of Internal Medicine.
Investigators analyzed data from the 1999 and 2007 National Ambulatory Medical Care Surveys, which included 20,959 (n = 8730 from 1999 and n = 12,229 from 2007) primary care visits for adults requiring treatment either for common symptoms and diseases such as fever, nasal congestion, anemia, and asthma or for general preventive medical examinations.
The researchers, led by Minal S. Kale, MD, from the Division of General Internal Medicine, Mt. Sinai School of Medicine, New York City, found a disparity in the provision of primary care for common symptoms and ailments that remained stable during the 8-year period: only 60% of primary care was dispensed by primary care physicians (PCPs; 58.1% in 1999 and 57.2% in 2007; P = .79). The balance for these types of primary care visits was covered by internal medicine subspecialists (9.1% in 1999 and 9.6% in 2007; P = .82), obstetrician-gynecologists (3.4% in 1999 and 2.8% in 2007; P = .36), and other subspecialists (29.4% in 1999 and 30.4% in 2007; P = .73).
The proportion of general preventive exams performed by PCPs and internal medicine subspecialists increased slightly, but neither change was statistically significant (66.3% in 1999 and 71.2% in 2007 [P = .44] and 7.1% in 1999 and 11.9% in 2007 [P = .22], respectively).Commensurate decreases were observed among obstetrician-gynecologists and other specialist physicians (16.1% in 1999 and 10.0% in 2007 [P = .13] and 10.5% in 1999 and 6.8% in 2007 [P = .39], respectively), which were also not significant.
Rebalance Requires Education
"This study highlights the fact that the US healthcare system is out of balance. If you look at research into the quality and cost of other industrialized nations, you see that their systems are based on primary care. In the United States, our physician workforce is approximately 70% subspecialists and 30% primary care physicians. We must work to rectify this and rebalance our system on primary care," Douglas Henley, MD, executive vice president and chief executive officer, American Academy of Family Physicians, told Medscape Medical News.
"Good-quality healthcare stems from that comprehensive approach and ensuring smooth transitions from one health setting to another, which are 2 of the hallmarks of primary care," Dr. Henley added, noting that primary care physicians are the "front door" for the healthcare system, providing diagnoses and treatment for routine and complex/chronic illnesses and coordinating other healthcare team members.
According to the study authors, explanations for the large proportion of specialist visits may include patients' belief that specialists provide superior care for all ailments, as well as the well-documented shortage of PCPs in the United States.
Dr. Henley concurred: "It's possible that people who seek primary care from subspecialists don't understand that subspecialty physicians have a more focused practice and work with particular disease processes, rather than on comprehensive primary care," he said.
"Therefore, they don't provide whole-person care that prevents illness or complications from a chronic condition the subspecialist might be treating. This is at the core of why our healthcare system is fragmented, why we see so much duplication of tests and procedures, unnecessary hospitalizations and re-hospitalizations, and why we have lower-quality outcomes," he concluded.
According to Dr. Henley, implementation of the Affordable Care Act will help the educational and economic environment for primary care physicians, build the primary care physician workforce, and enable Americans to have access to the patient-centered medical home.
To this end, Dr. Henley explains, the act includes provisions for programs such as the National Health Service Corps, which provides financial aid for medical students choosing to practice primary care; implementation of the Primary Care Incentive Program, in which Medicare pays a 10% incentive for primary care services provided by a primary care physician; and the Comprehensive Primary Care Incentive, a patient-centered medical home demonstration in which Medicare, Medicaid, and private insurers pay a per patient, per month coordination fee.
"The Affordable Care Act is moving to reform our health delivery system so that the nation has a strong primary care physician workforce and so that patients understand the invaluable role of the primary care physician in providing comprehensive, coordinated care," Dr. Henley said.
The study was not commercially supported. One author has received compensation as a board member for FAIR Health Inc Scientific and has received grants from Medtronic Inc and Pew Charitable Trusts, the National Institute on Aging, the American Federation of Aging Research through the Paul B Beeson Career Development Award Program, and the Centers for Medicare and Medicaid Services. The lead author is supported by the Mount Sinai Primary Care Research Fellowship, funded by the Health Resources and Services Administration through the Ruth K. Kirchstein National Research Service Award. Dr. Henley has disclosed no relevant financial relationships.
Arch Intern Med. Published online August 20, 2012. Abstract
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