PAFP Member, Samidha S. Bhat, MD, on Why Primary Care Matters

In an original article, PAFP member, Samidha S. Bhat, MD, explores the major benefits of and challenges to family medicine and primary care within the current U.S. health care system. An edited, short version of the article appears below and in the Summer 2021 issue of Keystone Physician magazine. The full article is available for download as a PDF here. 

The following introduction to the article is an excerpt from the edited version: 

Health Benefits of Primary Care

Much research has been done during the past two decades citing the value of primary care. Why, despite all the evidence and research about our worth, are primary care physicians still struggling to gain traction in the system?

By Samidha Bhat, MD

As a primary care physician who has been practicing for about 13 years, I can’t help but realize how much we do, apart from just seeing patients. More and more evidence shows positive correlation between primary care and better health outcomes. Primary care also helps prevent illness and death. Increased access to primary care decreases health disparities related to social, economic and racial reasons, therefore creating more equitable distribution of health in populations as seen in national and cross-national studies. But there are less funds and fewer resources available for primary care, and more pressure and demoralizing volume-incentive-based pay structures. Job satisfaction is low and burnout rates are high.

The Big Problem

Primary care became a “specialty” for post-graduate training in the late 1960s and early 1970s. This recognition produced two reports from Institute of Medicine that defined primary care as “provision of integrated, accessible health care service by clinicians who are accountable for addressing large majority of personal health care needs, developing sustained partnership with patients, and practicing in context of family and community.”

These reports were also used to measure four main features of primary care services:

• First contact access
• Long-term, person-focused care
• Comprehensive care for (most) health needs
• Coordinated care if sought elsewhere

With above measures in mind, the primary care specialty was designed to work hand-in-hand with specialists and strive to work on prevention so as to maintain patient health, while keeping social aspects in mind. But today it feels like a tug of war, and we must remind ourselves this is not a fight against the system. It is also not a battle of PCPs versus specialists; rather, it is a push for effective collaboration and integration.

Most physicians feel extremely rewarded when they are able to help patients (an intrinsic reward). Unfortunately, this reward often feels stripped off due to more administrative or “non-clinical” work and therefore burn out. With some introspection, I have also felt that part of the problem could be a sense of dispiritedness, wherein physicians become disengaged and, to some degree, resistant to change.

Problem Discussion

Primary care providers are the first point of contact with health care system for patients, be it for simple or complex disease processes. Although they attend to a full spectrum of issues, PCPs often do not feel empowered due to various manacles — from health plans, insurance companies and the conflicting goals of their administration. Less transparency from administration adds to the frustrations, especially in organizations that are hierarchical rather than collaborative. Such organizational structures and systems drive behavior, causing primary care providers to focus more on tactics and less on strategy. Monetary compensation, poor recognition and almost non-existent growth opportunities are also part of the challenge.

Let’s also talk about burnout of the most valuable professionals in the health care system. Professional burnout is characterized by loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment. This may lead to early retirement, alcohol use and suicidal ideation. In 2013, a survey of 508 employees working for 243 health care employers found that 60 percent reported job burnout and 34 percent were seeking a different job. Complaints included heavy patient loads, small staffs and high stress levels. The drivers of this situation could be ever-increasing aging population, their increased needs, significant racial-ethnic disparities, socio-economic disparities in health states, increased ER utilization and changes in compensation structures.

Burnout is due to fewer available resources, more work required from physicians (in addition to taking care of patients), less support staff (and therefore longer hours doing non-clinical work), increasing ratio of physician to patients (one physician to almost 2,700 patients and maybe more). This leads to shorter visit times, so as to fit additional patients in the day, creating scarcer communication about state of health and allowing less time for educating about ER/urgent care utilization and discussing advanced care planning. All of these factors have the potential to increase dissatisfaction among primary care providers. Dissatisfied physicians are two to three times more likely to leave practice, thereby exacerbating the growing shortage of primary care physicians and complicating the achievement of a healthy population.

At least 55 percent of office visits are in primary care offices, yet only 4-7 percent of health care dollars are offered to primary care. This is a major misalignment of reimbursement compared to other specialties and needs to be relooked at. Medical students do not want to go into primary care with more work, more burnout and no career growth. This is adding to misbalance.

Furthermore, primary care is still one of the lowest as far as compensation. To assure an adequate primary care physician workforce for the future, it is essential to bring primary care income levels up to par in relation to those of other physician specialties. Overall, the United States still has a serious imbalance between the production of primary care physicians and those in other specialties.

Data And Statistics

The 1998 National Medical Expenditure Survey compiled data from a nationally representative sample of 13,270 adult respondents, and recorded whether respondents’ personal physician was either a primary care physician or specialist, requested information about their total annual health care expenditures and measured their five-year mortality experience. Respondents with a primary care physician as a personal physician, rather than a specialist, reported fewer medical diagnoses, higher health perceptions, lower annual health care expenditures and lower mortality.

An American Journal of Public Health study estimated that more than a third of Americans on Medicare who were 65 and older had a regular physician they had been seeing for a decade or more — and those with the longest ties had lower medical costs and were less likely to be hospitalized than those with the shortest.

David Meltzer, MD, PhD, an economist and a primary care physician at the University of Chicago, reported that doctors spending more time with their patients actually saves money. After a year in his clinic, he noted that patients had 20 percent fewer hospitalizations than their control-group counterparts.

That adds up to big savings. Medicare costs average $50,000-$75,000 each for hospitalization. If there are approximately four primary care physicians working in an office, the access and care they can provide to avoid even one hospitalization per physician per month equals 48 avoided hospitalizations and saves approximately $2.4 million (48 x $50,000) to $3.6 million (48 x $75,000). By comparison, the average family physician annual salary per year (2020, Salary.com) is $207,905 and for four physicians adds up to less than $1 million.

A study published in PubMed shows if everyone saw a primary care provider first the US could save up to $67 billion, just by avoiding urgent care, emergent care and specialist visits.

Long-term, focused care helps catch and treat problems early on and reduces specialist visits. US adults who have a primary care physician have 33 percent lower health care costs and 19 percent lower odds of dying than those who see only a specialist. Family physicians can also add value to the larger economic system by finding ways to keep workers healthy and on the job, thereby reducing the costs of health-related work absenteeism.

Conclusion & Solution

Improvement in health of populations is likely to require a multipronged approach that addresses socioeconomic and behavioral determinants of health and strengthens certain aspects of health services. The fact that primary care, particularly family medicine, was found to be associated with better health outcomes suggests that improving the ratio of primary care (especially family medicine physicians) to population could improve health outcomes, even in states with serious health inequalities.

Beneficial impacts of primary care on population health have been studied to be achieved with six mechanisms:

• Greater access to needed services
• Better quality of care
• Greater focus on prevention
• Early management of health problems
• Cumulative effect of the main primary care delivery characteristics
• The role of primary care in reducing unnecessary and potentially harmful specialist care

The overall benefits of primary care are not just for patients and healthy outcomes; they also contribute to an overall increase in health care provider job satisfaction and offer incredible savings for patients and health plans.

When I consider this incredible value created by primary care, I see following attributes:

• Patients present with hope of being treated, in most cases, by their primary care provider without referral.
• PCPs help navigate patients through the health care system for referrals, if needed.
• PCPs help build trust for overall decision-making process.
• Due to long lasting relationships, PCPs also provide opportunities for disease prevention and health promotion.
• Eventually primary care helps bridge gaps, not just at personal levels but at community levels — helping one patient at a time.

This clearly proves that primary care has an impact on an entire health care ecosystem as compared to the microcosm in which we are evaluated. Therefore, with all above factors in mind, physicians should focus on some key issues:

• Attribution: Are the patients I’m being measured on “my” patients?
• Scope: Are the scope of services in the measurement program within my influence?
• Comparators: With whom or what am I being compared?
• Reliability/Validity: Does the measurement program include reliable, valid measures?
• Statistical Testing: Does the program include appropriate statistical testing to ensure that measured differences are likely to be real and not random variation?
• Risk Adjustment: Does the program adjust appropriately for risk?

I believe the solution is to focus on these key issues and proven benefits — and to consider the intangible value created by primary care providers, which is often overlooked.

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Bhat is licensed to practice medicine in Florida and Pennsylvania and is board-certified in family medicine by the AmericanBoard of Family Medicine. She completed her residency inFamily Medicine at UPMC McKeesport in Pennsylvania. She also graduated with a Master of Business Administration degree from the Joseph M. Katz Graduate School ofBusiness at the University of Pittsburgh.