Primary care is the backbone of any high-performing health care system. It works best when primary care providers sit at the center of a patients’ health care experience and are aware not only of their medical needs but also of their social needs: Do they have food, housing, heat, a way to get to their appointments?
Coordinating what can be a complex nexus of specialty care and social services for patients is a challenge that physicians the world over are grappling with. Our survey of more than 13,000 primary care physicians in 11 high-income countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States), published Tuesday in the journal Health Affairs, shows where the U.S. is falling behind, where we are keeping pace, and possible paths to improvement.
Primary care doctors in the U.S. and some other countries fall short in provider-to-provider communications and in exchanging patient information electronically. Only about half of U.S. physicians reported that they are usually notified when one of their patients is seen in the emergency department or admitted to a hospital. Compare that with 79% to 85% of physicians in the Netherlands and New Zealand who reported usually receiving these notifications.
About half of U.S. physicians reported being able to exchange patient information, such as clinical summaries, laboratory tests and medication lists, with physicians outside their practices. In contrast, 72% to 93% of physicians in the Netherlands, New Zealand, Norway, and Sweden reported these abilities.
On a brighter note, U.S. physicians were the most likely to report offering patients electronic access to their health care information through portals and web tools that enabled them to make appointments, refill medications, and see visit summaries and lab tests online. These patient-facing electronic services reflect the priority the federal government has placed on giving patients access to their health care information to achieve nationwide interoperability.
Primary care physicians in the U.S. and their counterparts around the world share significant challenges helping patients meet their health-related social needs. In most countries, physicians said they found it challenging to coordinate with social service providers to assure patients have things like good food or a living environment that accommodates their illnesses or disabilities. In the U.S., about one-third of physicians said that inadequate staffing, poor responses from social service agencies, or a lack of formal referral systems made it difficult to help provide patients with critical non-medical health-related services.
Here are three key strategies we identified that could help primary care physicians in the U.S. catch up with their counterparts elsewhere and better meet their patients’ diverse needs.
Vigorously enforce new federal regulations that require health care organizations to exchange health care information. Many primary care physicians work in large health care systems that may not have invested in or prioritized information exchange. The federal government has new regulations that, if properly enforced, could clear away some of the technical and economic barriers to passing information among physicians and other health care providers.
Develop payment systems that cover the costs of providing social services that are essential to medical care. A good example of this is medically prescribed foods for people with diabetes, which have been proven to be effective in reducing costs of care.
Share savings with social service organizations when their work with primary care physicians results in health care savings. Social service organizations often operate on shoestring budgets compared to better-endowed health care providers and cannot uphold their end of the care coordination partnership unless they have better staffing and information systems.
The U.S. lags most of the world in making primary care a top priority. That said, it has strengths to build on — nearly all primary care practices in the U.S. have electronic medical records, and providers, health systems, and payers see the value of supporting patients’ unmet social needs and are looking for the best ways to support them.
A strong emphasis on primary care across our health care system and continued benchmarking of U.S. health care performance against that of other wealthy nations will point us to a higher-performing health system.
Michelle Doty, Ph.D., is vice president of survey research and evaluation for the Commonwealth Fund. David Blumenthal, M.D., is president of the Commonwealth Fund.
I applaud the work of Drs. Doty and Blumenthal. However, coordination of a patient’s care was not a problem during my years of surgical practice from 1974 to 1998. If I saw a patient in the emergency room who was referred to me, I always called the referring physician after my examination. In the office, I called the referring physician if the problem was not routine or if the patient needed urgent surgery. After surgery, I called that same physician to describe the surgery and reaffirm their diagnosis or what condition I had actually found and thanked him/her for sending the patient. When the patient was discharged from the hospital, I called that same physician and described the hospital course, what consults had been done, any changes to medications, and that the individual would be calling for an appointment to see him/her in follow up and to expect a discharge summary. I dictated a 1 1/2 page discharge summary (longer if the hospital course was prolonged), with specific instructions to send a copy to the physician – by name. If I examined an unreferred patient in the emergency room, I called the patient’s physician even if he/she was not among my regular referring physicians. I made these calls for two reasons:
1. They were important for continuity of care and to keep the patient’s physician informed.
2. Each call was a marketing opportunity for me and my surgical practice in a competitive environment. I wanted to highlight my good care and the astuteness of the family physician (PCP) in getting the patient to a surgeon. My colleagues made the same calls for the same reasons. I understand the increased demands on a clinician’s time that dwarfs the oversite and reporting required of us. Still, the best way to ensure continuity of care is to pick up the phone or send a text or email if that is the preferred method in this age of technology. We need to talk to each other.
Robert E. Leibowitz, MD, MHA, FACS
Commonwealth should first attend to its mission for health access and
1. Stop pushing expansions of health insurance that fail to support primary care where needed (and Basic Health Access)
2. Stop pushing costly and distracting metrics, measurements, and micromanagements that divert what little funding goes to local workforce where most needed from counties lowest in workforce, dollars, jobs, and economics to places and corporations highest in concentrations.
Commonwealth needs to focus on the support of the team members delivering the care if it every hopes to improve basic health access or move the nation to higher functioning primary care.
There are 2 most important elements of higher functioning primary care within practices
1. More team members are needed for practices serving half of the US population
2. Better team members are needed for these practices
This requires a better financial design.
There are 2 elements that are important for higher functioning primary care outside of primary care practices
1. State and federal designs must support twice as much social support resources for this half of the nation with half enough
2. State and federal designs must support at least 50% more general specialists and their team members across mental health, women’s health, general surgical services.
Generalist and general specialist services are 90% of the local services where most Americans most need care. Only a changed financial design can address these areas.
You cannot integrate, coordinate, outreach, or do other higher functions if you do not have the primary care teams, the general specialists, or the local social support resources.
More and better health care delivery team members requires a much better financial design – not the sad mockery that CMS, states, and insurance “payers” grudgingly and painfully contribute.
True reforms that change the financial design must also be accomplished despite the resistance of those who benefit from procedural, hospital, technical, and highly specialized care – that will require cuts to accomplish the necessary revenue to build Basic Health Access.
Not since 1965 – 1978 has the nation injected more billions in the counties and places of need – a requirement for Basic Health Access and higher functioning primary care.
Once you understand that half of the nation has half enough primary care with steady declines caused by the financial design you can understand why there is poor communication, destruction of continuity, increasing turnover frequency and costs, worsening burnout, and other consequences.
Commonwealth and others must also consider the economics and dollar transfer changes over time. The perspective of most Americans most behind must be understood. These innovative designs hurt them. They are not helping.
1. Mandated insurance extracts many billions more from counties with the least and concentrates these dollars in places with the most. Because of the health care designs and the inadequate local workforce, only 10 cents on the dollar returns to local providers – Mandated insurance increases disparities that will shape worsening outcomes. Diversions of billions more health and education dollars
2. Metrics, measurements, and micromanagements divert billions from these practices and hospitals where most needed. The same is also true for education designs. Local school districts, hospitals, and practices need to be able to receive and keep dollars and spend them on jobs and other local areas.
If the designers do not examine shortages and deficits and access barriers and why innovations are not implemented – they should first seek and find the right perspective.