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Primary Care: Has It Been “Oversold?”

Citing a new study by the Dartmouth Atlas, the Wall Street Journal’s health blog provocatively asks: “Has the notion of ‘access’ to primary care been oversold?”

The Dartmouth researchers found “that there is no simple relationship between the supply of physicians and access to primary care.” That is, they found that having a greater supply of primary care physicians in a community doesn’t mean that the community necessarily has better access to primary care. Some areas of the country with fewer primary care physicians per population do better on access than other areas with more primary care physicians.

The researchers also report that the numbers of family physicians is more positively associated with better access than the numbers of internists, although they call the association “not strong.” Although both general internists and family physicians are counted as primary care clinicians, “in [regions] with a higher supply of family physicians, beneficiaries were more likely to have at least one annual primary care visit. In [regions] with a higher supply of general internists, fewer beneficiaries had a primary care visit on average.”

The study also suggests that the availability of primary care doesn’t always lead to better outcomes:

“For example, leg amputation is a serious complication of diabetes and peripheral vascular disease. A broad array of factors go into a patient’s risk of amputation, including obesity, smoking, poverty, and poor control of blood sugar, and preventing amputation requires diligent attention from both the patient and clinician. One might assume that, at a regional level, access to a primary care clinician would be a predictor of the risk of amputation. Yet … improving this outcome of peripheral vascular disease is much more complicated than simply ensuring access to primary care; there is no relationship between having at least one annual visit with a primary care clinician and the rate of leg amputation.”

So does this mean that ACP and others who have for years have argued that primary care is positively associated with better outcomes, access and lower costs have had it all wrong? I don’t think so. There are scores of studies that show that primary care is associated with better outcomes and lower costs of care.

And a careful reading of the Dartmouth study shows that the researchers share the belief that primary care is the “backbone” of health care, that “primary care physicians can play a crucial role in ensuring that patients get high-quality care” and that “primary … care that does a good job of managing chronic disease can prevent hospitalizations.”

What’s the story, then? The main point of the Dartmouth study isn’t that primary care doesn’t matter — it does — but that it is much more than a numbers game.

Dartmouth suggests “that primary care is most effective when it is embedded within a health care system that allows the coordination of primary care services with those delivered by specialists and hospitals.” This is one reason why ACP has been so insistent on championing the concept of the Patient-Centered Medical Home, which has as a central purpose facilitating coordination of care through a well-organized primary care practice that has relationships with teams of nurses, physician assistants and other specialists.

My answer to the Wall Street Journal health blog question “has primary care been oversold?” is an emphatic, heck no! But the study does remind us that as much as we need to ensure a sufficient supply of primary care physicians, we also need to learn how to organize primary care to achieve the best results, such as through Patient-Centered Medical Homes. My concern is that policymakers may instead simplistically point to the Dartmouth study as a reason not to invest more in training and retaining primary care physicians.

Today’s questions: What is your reaction to the Dartmouth study? And how would you answer the Wall Street Journal blog’s question: “Has access to primary care been oversold?”

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*

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