A study of more than 9,500 people with either high blood pressure or high cholesterol, which was published in the American Heart Journal this past July, sheds a little more light on why this relationship works so well. It found that having a usual source of care—a primary care provider or clinic—significantly decreased a person’s risk of going untreated for high blood pressure or high cholesterol whether or not the individual had insurance. This finding suggests that health reform has to do more than provide affordable health coverage for all who need it. It must also ensure access to a primary care provider.
Primary care has delivered some of its greatest gains in the African-American population. One study from 2005 showed that access reduced deaths in that group four times more than in whites—even after controlling for education and income. Part of the difference probably has to do with the slightly higher rates of hypertension among African-Americans. Treating high blood pressure is a proved way of preventing heart attack, stroke and kidney failure. Part of the difference also probably has to do with regular screening for cancers—such as colon and cervical—that are readily treatable if caught early. “In the cancer realm, a lot of the difference [between racial/ethnic groups] is lack of insurance and lack of a usual source of medical care,” says Ann S. O’Malley, a primary care physician who is a senior researcher at the Center for Studying Health System Change in Washington, D.C. Both lines of evidence strongly suggest that making primary care more broadly available could go a long way toward decreasing health disparities among whites, blacks and other racial/ethnic groups.
Among wealthier people, a big, perhaps surprising benefit of primary care is that it keeps patients from going too often to a specialist, where they can be overtreated or misdiagnosed. “Most people do not realize the dangers of too much specialty care,” says Barbara Starfield, a health systems researcher at the Johns Hopkins Bloomberg School of Public Health. She points to research showing that primary care physicians are better all-around diagnosticians than specialists and achieve better overall health outcomes for their patients. Unnecessary treatment turns out to be a bigger problem than most people in the medical field—including specialists—care to admit. Every test, every diagnostic procedure, every surgery has its own complication rates. For example, undergoing cardiac catheterization to see if the arteries in your heart are blocked slightly increases the risk of fatal internal bleeding—which is why you have to lie so still after the procedure.
Primary care is not a panacea, of course. Sometimes you really do need a brain surgeon to save your life. But more and more high-performing health care networks are noticing the benefits and reorganizing care delivery, as a report by the Josiah Macy Foundation concluded in the spring. After North Carolina restructured some of its pediatric Medicaid programs in the late 1990s to emphasize primary care—providing more evening and weekend appointments and paying for more follow-up visits—hospitalizations for asthma dropped by 40 percent. In 2007 the Group Health Cooperative in Washington State determined that patient satisfaction was up, visits to the emergency room were down, and costs were lowered just one year after it started providing more primary care services.
Of course, for the nation to reap the advantages of primary care, it must have enough practitioners. The health reform laws of 2010 increased the payment for some primary care services by 10 percent, but it did not go far enough to address the growing shortage of providers, Starfield and O’Malley say. Physicians are retiring from or leaving primary care in droves because it does not pay as well as specialty care. Advanced practice nurses and other health care workers who could meet more of the demand are hamstrung by outdated state regulations. “I am a primary care–trained physician, and I can’t find a primary care provider for myself,” O’Malley says. Access is likely to get tighter. The Congressional Budget Office estimates that an additional 32 million previously uninsured people will have health coverage as a result of the health laws of 2010. If health care reform is going to succeed, they—like the rest of us—will need to find a primary care provider.