William Cayley: Is primary care in the US really the future?

bill_cayleyIs primary care really the future? I’d like to say “Yes,” but I’m not so sure… (at least in the USA).

There has been much talk and writing about the growing need for primary care physicians to serve our population, and one “promise” of the Affordable Care Act is “its potential to make primary care more accessible.” At the same time, the major family medicine organizations in the USA have embarked on an ambitious project to “examine the challenges and opportunities facing family medicine today, and define a path forward in the context of a rapidly changing healthcare landscape.

All of this should be reassuring, especially in light of Starfield’s oft-cited demonstration that “primary care helps prevent illness and death,” but I’m not sure what sort of growth in primary care we are actually seeing. A report released last week by the IMS Institute for Healthcare Informatics found that in the USA in 2013 “primary care visits continued to decline for the fourth consecutive year,” while specialist visits increased by 4.9%. At the same time, the hospitalist movement continues to grow in the USA, despite the fact that hospitalist care may lead to higher medical utilization and costs after discharge, and health economics research continues to explore (among other things) how primary care can provide “downstream revenue” to specialty physicians and services.

Are we really seeing the growth of primary care, that is, the development and support of a solid and well-trained primary care workforce, empowered and encouraged to provide the breadth, depth, and continuity of care that can improve our patients’ lives?

Or are we seeing the growth of a system that views primary care as a pipeline to feed specialty services, or a source of patient referrals to bolster income?

I’m a family doc and I love what I do—and while I hope for the first vision to become reality, I’m becoming increasingly concerned we are actually seeing the development of the latter.

Competing interests: “I declare that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare—I’m just a family doc!”

William E Cayley Jr practises at the Augusta Family Medicine Clinic, teaches at the Eau Claire Family Medicine Residency, and is a professor at the University of Wisconsin, Department of Family Medicine.

  • Mark Murphy

    Interesting. Thanks for blog.

    General practice is the future- but not when it partially gatekeeps into a privatised system where cream is being skimmed left right and centre.

    A failure to develop general practice in the US is caused the market model of competing healthcare insurers on one side and competing healthcare providers on the other. US. Insurers reimburse, providers get paid for and ‘costumers’ want health-related procedures. Primary care, also, is underdeveloped in this context. Managing multimorbidity in general practice is at odds with the marketing/ advertising and promotion of specialisation and pharmaceuticals in the US media.

    It is not enough to talk about the importance of general practice and access. I think the UN/ WHO and other international bodies need to recognise the role that for-profit providers and insurance companies play in the role of moral hazard, overtreatment, care for the most vulnerable in society and sustainability.

  • JM

    Primary care will flourish if Family Medicine truly embraces the concept of medical home and builds an environment which supports population health via mid-level practitioners, health coaching, setting good examples personally, etc. The big variable continues to be patient accountability – without it costs will continue to skyrocket. Every problem has a solution, yet it often requires sacrifices individuals are unwilling to make. JM