Chapter 1 of family medicine

1. CHAPTER 1: PRIMARY CARE AND THE
EVOLVING US HEALTH CARE SYSTEM.
FAMILY MEDICINE 1

2. CLINICAL OBJECTIVES
• CLINICAL OBJECTIVES
• 1. To present evidence supporting the role of primary care in an ettective health
care system.
• 2. To describe the principles of good primary care.
• 3. To describe how primary care is evolving to provide higher quality care, and
the innovations within healthcare that are fostering this evolution.

3. US HEALTH CARE HIGH COST AND MIXED RESULTS
• Several reports have compared US health care with that of other developed countries.
• Among the points that can be made about these comparisons are the following:
• US health care is expensive, consuming 16% of our gross domestic product. Switzerland,
which has the second most expensive health care system in the world, spends 61% as much
as we do per capital.
• In spite of the money we spend, the United States lags behind every one of these comparison
nations except Mexico in the key health care outcome indicators of life expectancy and infant
mortality.
• Our increased health care costs are not due to having too many doctors or using hospitals
too much. The United States is in the middle of the pack in both measures of health care
resources; in fact, our hospital utilization is less than that of Germany, France, Switzerland,
and the United Kingdom.
• One contributing factor to the high cost of US medicine appears to be overemphasis on
technology, and the potential for its use to be influenced by financial interests. Compared
with most other industrialized nations, the US excels in performance of computerized
tomography scans,magnetic resonance imaging studies e.t.c.

4. • One contributing factor to the high cost of US medicine appears to be
overemphasis on technology, and the potential for its use to be influenced by
financial interests. Compared with most other industrialized nations, the US
excels in performance of computerized tomography scans , magnetic resonance
imaging studies e.t.c.
• Another contributing factor appears to be the fragmentation and administrative
complexity and resultant inefficiencies of the US health care system, with little
continuity or coordination of care, which has been implicated not only in higher
costs of care but also in the high frequency of medical errors.

5. • In a thought-provoking essay from 2009, Atul Gawande attempted to examine
within the United States for factors impacting health care prices.
• He accomplished this by contrasting two counties in Texas that were close by and
had comparable demographics and health results but radically varied per capita
health care prices.
• He came to the conclusion that the main factor influencing health care costs was
physician behavior.
• He came to the conclusion that "the most expensive piece of medical equipment
is a doctor's pen," and that physicians are crucial in deciding both health
outcomes and health costs.

6. • But, physicians do not function in a vacuum, and the incentives and disincentives
of the system in which they operate have a significant impact on their behaviour.
• The US healthcare system has undergone a thorough review as a result of these
causes, which over the past ten years have also set in motion developments that
are altering and will continue to alter how medicine is practiced in the future.
• The Affordable Care ("health care reform") Act of 2010 included some of these
forces, but many more are currently being sponsored by businesses, governments,
or healthcare organizations.
• Yet, given how quickly the health care system is changing, it is more important
than ever for today's students and professionals to become knowledgeable about,
involved in, and leaders of the changing health system.

7. ROLE OF PRIMARY CARE IN A WELL- FUNCTIONING HEALTH CARE
SYSTEM
• The most economical health care systems in the world depend heavily on primary care
physicians. In the United States, this is also accurate.
• How does a greater emphasis on primary care lead to better, more cost-effective overall
health care? When patients have a primary care physician as the regular source of care:
• Care is integrated, personalized, and prioritized.
• Preventive services are more consistently delivered.
• Chronic diseases, such as asthma, cardiovascular disease, and diabetes, are better
managed.
• Acute problems are diagnosed and treated earlier.
• People with low incomes tend to have greater access to care and, concomitantly, fewer
disparities in health outcomes
• Primary care physicians tend to be active at a community level to improve health care
resources and attitudes for both healthy patients and those with chronic diseases.

8. • Consequently, both primary care physicians and subspecialists are necessary for a
healthy healthcare system.
• Currently, speciality care has a slight advantage in the US. The Annals of Internal
Medicine published a 2008 analysis that came to the conclusion that "investing in
primary and preventive care can result in better health outcomes, reduce costs," and
that "the nation's workforce policy must focus on ensuring an adequate supply of
primary and principal care physicians trained to manage care for the whole patient.“

9. DEFINING AND DESCRIBING PRIMARY CARE
• Primary care is defined as “integrated, accessible health care services by clinicians
who are accountable for addressing a large majority of personal health care needs,
developing a sustained partnership with patients, in the context of family and
community.
• Primary care providers include family physicians; general internists; general
pediatricians; family, adult care, and pediatric nurse practitioners; some physician
assistants; and some gynecologists.
• Because they provide care that is aimed at preventing adverse, costly events such as
hospitalizations and further morbidity, primary care physicians are well positioned to
address national health priorities.

10. • A comprehensive study of the activities of family physicians directly observed. Among
the findings of that study follows :
• An extensive variety of common, rare, and undifferentiated problems are managed in primary
care.
• Prevention is practiced broadly in primary care visits, and not just during “physicals.” During
32% of illness visits, the family physician delivers at least one service recommended by the
US Preventive Services Task Force.
• Mental health problems present frequently and are often managed without referral. For
example, in 18% of visits, family physicians either diagnose or provide counseling related to
depression or anxiety.
• Patient education is a major part of primary care practice. Fully 90% of office visits, and 19%
of visit time overall, involve patient education or health habit advice.
• Care is often provided in the context of family. Seventy percent of patients have another family
member seeing the same physician.
• Coordination of care is common. During 10% of office visits, a referral is made to a medical
specialist, mental health provider, physical therapist, social worker, or other health
professional.

11. PRINCIPLES OF A GOOD PRIMARY CARE
• Access to Care. Primary care should be readily available. Open access is one way of helping
assure this.
• Continuity of Care. Seeing the same provider over time is called continuity of care.
• Team-based, Comprehensive, Personalized Care. A family physician manages without
referral between 85% and 90% of patient problems. This provision of a wide variety of
services, covering the majority of patient needs, is termed comprehensiveness of care.
• Coordination of Care. Primary care providers help their patients negotiate the complex
health care system by serving as coordinators of care.
• Community Orientation. Although most of the physician’s work is at the patient level, good
primary care physicians also seek to improve the broader health of the community.
• Prevention Focus. Preventive care is the most common reason patients visit a family
physician’s office. Among the facets of preventive care are measures to reduce disease risk,
such as assistance with smoking cessation; immunizations; measures to prevent morbidity
in people who have established disease.

12. PRINCIPLES OF A GOOD PRIMARY CARE CONTD
• Patient Self-empowerment and Self-management. Effective chronic illness care
requires a partnership in which medical providers help the patient acquire the
knowledge, skills, and self-empowerment to manage risk factors, monitor the illness,
and make adjustments in their care.
• Evidence-based Practice. Exemplary primary care is evidence-based. By this we mean
that the primary care physician has access to and uses effectively what is available in
the literature to guide practice.
• Family Orientation. Quality primary care must take into account the family context. By
family we mean the entire range of relationships whether or not by blood or marriage
that can comprise a patient’s close social network.
• Biopsychosocial, Life-cycle Perspective. Effective primary care physicians view
patients from a broad perspective, taking into account physiology, physical illness,
emotional health, and the social, occupational, and environmental context within which
the person lives.

13. • The patient-centered medical home (PCMH) is a model of health care delivery system
reform that incorporates virtually all of the principles of family medicine elucidated
previously.
• The PCMH has four cornerstones:
• 1) comprehensive, coordinated primary care delivered by a team of providers led by the
patient’s personal physician.
• 2) patient-centered care, tailored to individual needs and preferences.
• 3) a high-tech practice model that includes patient registries, quality monitoring and
improvement, point-of-care decision support, and electronic health records.
• 4) a reimbursement system that includes payment for care coordination and for
achievement of quality of care benchmarks, as well as fee-for-service and case-mix
adjustments for practices serving patients with complex chronic illnesses and multiple
comorbid conditions.

14. • Community health centers (CHCs) are a large, growing provider of primary care, especially
for poor, minority, and uninsured Americans.
• CHCs receive federal funding to provide primary care as a major component of the “safety net”
for people with limited financial resources.
• CHCs are increasingly using electronic medical records; engaging in quality monitoring and
improvement programs and employing comprehensive health teams including physicians,
nurse practitioners, physician assistants, dentists, nutrition counselors, social workers, nurses,
and others.
• Overhead expenses from support staff devour around two-thirds of a primary care practice’s
revenue. By reducing this overhead to as low as 20% of revenue by operating on a cash only
basis with limited office staff, low overhead practices can see fewer patients per day and
charge far less per visit.
• Patients find them appealing because the total cost of care is often no more than they would
expend as the co-pay under traditional insurance.
• Physicians find them appealing because they are able to spend more time with patients and
generate a similar income to that of more traditional practices.
• Another rapidly growing form of low-overhead practice is the home care or nursing home
practice.

15. • Health Care Reform and Primary Care One of the forces most strongly shaping the direction
of health care in this decade will be implementation of the Patient
• Protection and Affordable Care Act of 2010 (“health care reform” bill). A key feature of health
care reform is investment in an improved primary care system
• Among the legislative provisions of health care reform and related congressional initiative are
the following, which directly impact primary care:
• Increased payments for primary care under Medicare and Medicaid,
• Incentives for practices to meet the requirements for certification as medical homes,
• Improved access to care for low-income and uninsured people through expansion of
community health centers and the National Health Service Corps,
• A requirement that insurance plans provide free preventive care for services that have
sufficient evidence supporting their effectiveness
• Investment in primary care training.
• Special financial incentives for practices to adopt electronic medical records and to use them
to monitor and report quality indicators.
• As a result, the coming decade will be one of rapid growth and evolution in primary care.