History and Overview

Outpatient and primary care is arguably the most important facet of health care, but it hasn’t always been. In the early days of modern medicine, most physicians practiced alone in their community. The advent of technology and improved diagnostic and treatment capabilities caused a decrease in outpatient treatment options largely due to the need to aggregate technological resources in close proximity to a larger group of physicians. In the last several years however, we have seen a reversion to outpatient care and an increased importance in primary care (Shi & Singh, 2008). This is due to the need to decrease cost, increase access, and better the quality of care.
Primary care is vital to increasing access. In the United States there are an estimated 45 million individuals who are uninsured. Eighty percent of those individuals are employed or live with an employed adult. 18 million of these individuals have a family income over $50,000 per year (Kaiser, 2010). Because 75 – 85% of the United States population seeks primary care in a year, attention to this aspect of health care is crucial (Shi & Singh, 2008).
Primary care is central to decreasing cost. Because primary care appointments cost less on average, we can receive more with less money. For example, the average bill from a family practitioner is $62, a bill from a specialist can be upwards of $90 (AAFP, 2010; Figure 1). Primary care costs less because these physicians orders less tests and receives the same or better results than specialists. This decrease in tests is also correlated with a decreased iatrogenic complication (Shi & Singh, 2008). While an estimated 50% of emergency department visits would be better handled in the primary care setting, patients who lack insurance continue to overrun emergency departments to get their necessary care (Shi & Singh, 2008).

Primary care certainly betters the quality of care. This has been shown with epidemiological data. We see areas with a higher ratio of primary care physician yield better health results. Several studies have shown that an increase in primary care providers in a given region have yielded a decrease in cancer, heart disease, stroke and infant mortality, in addition to a decrease in low birth rate, and an increase in life expectancy. Furthermore, an increase of just one primary care provider per 10,000 individuals has shown to decrease mortality by 5.3% (County Health Rankings, 2010). In the U.S., about 43% or practicing physicians work in the primary care setting as opposed to 50% and 70 – 72% in Canada and Great Britain, respectively (Shi & Singh, 2008; Figure 2). Both of these countries are ranked higher than the U.S. on the World Health Organizations list (World Health Organization, 2010).

As the foundation of our country’s health care system, primary care is currently relatively weak. Over the previous eight years, we have seen a 20% increase in specialization by internal medicine residents resulting in less primary care providers and yet more specialists. Additionally we have seen 15% fewer residency spots filled in the U.S., while half of these positions are being filled by foreign graduates (Riselbach, et al).
Given the preceding information, it should be quite clear that consideration of primary care is essential to the success of health care reform. While this may be one of the most important pieces, we concede that without a system for providers to work in improvement will be negligible.

References

Shi, L., & Singh, D. A. (2008). Delivering health care in America: a systems approach (4th ed.). Sudbury, MA: Jones and Bartlett Publishers, Inc

Henry J. Kaiser Family Foundation. (2010) www.kff.org. Accessed 2/19/2010.

American Academy of Family Physicians (2010) www.afp.org. Accessed 2/19/2010.

County Health Rankings (2010) Access to Care. www.countyhealthrankings.org. Accessed 2/19/2010

World Health Organizations (2009). www.who.int. Accessed 2/19/2010.

Rieselbach, R.E., Crouse, B.J., Frohna, J.G. (2009) Teaching Primary Care in Community Health Centers: Addressing the Workforce Crisis for the Underserved. Annals of Internal Medicine.

Beliefs and Values

The World Health Organization (2010) defines primary health care as

Essential health care based on practical, scientifically
sound, and socially acceptable methods and technology made universally
accessible to individuals and families in the community by means acceptable to
them and at a cost that the community and the country can afford to maintain at
every stage of their development in a spirit of self-reliance and
self-determination. It forms an integral part of both the country's health
system of which it is the central function and the main focus of the overall
social and economic development of the community. It is the first level of
contact of individuals, the family, and the community with the national health
system, bringing health care as close as possible to where people live and work
and constitutes the first element of a continuing health care process.

Primary care plays a central role in a health care system. Traditionally, primary care has been the cornerstone and conceptual foundation for ambulatory health services, or outpatient care, as well (Shi & Singh, 2008, p. 247-248). Therefore, a strong primary care delivery system is essential to creating an efficient outpatient care delivery system in reforming the United States health care system.

We believe that primary care is a right that should be provided to all American citizens. The World Health Organization's definition of primary care includes the phrases, "Essential health care...made universally accessible." It has been estimated that 75-85 percent of people in a general population require only primary care services in a given year. Additionally, Americans, on average, make three visits per year to physician offices, with the most common reason being a general medical examination (Shi & Singh, 2008, p. 247). With the provision of properly provided primary care services, the United States health care system could become more cost-efficient, as prevention and primary care cost less than secondary or tertiary care and provide greater benefits. A continuum of health care is essential not only for individuals, but also for communities, to enable a country's social and economic development. A health care delivery system that lacks universal access is ill-equipped to meet that objective.

We also believe that primary care providers should act as gatekeepers. This practice is already used by managed care organizations in the United States, where many Americans view this as a threat to their freedom of choice. However, the intervention of primary care protects patients from unnecessary procedures and over-treatment because specialists tend to use additional medical tests and procedures more often than primary care providers. The additional procedures also increase the risk of iatrogenic complications. When a person's comprehensive health care needs are coordinated by a trained primary care professional, it leads to better health outcomes and cost-efficiency (Shi & Singh, 2008, p. 282).

Shi, L., & Singh, D. A. (2008). Delivering health care in America: a systems approach (4th ed.). Sudbury, MA: Jones and Bartlett Publishers, Inc.

World Health Organization. (2010). Primary health care. Retrieved February 14, 2010, from http://www.who.int/topics/primary_health_care/en/

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