Domhnall MacAuley: The US champions primary care

Domhnall MacauleyWhen the US starts to champion primary care, it is time to sit up. With its traditionally specialist focus, this may seem out of character, but as a result of the Patient Protection and Affordable Care Act, there is increasing focus on family medicine. In a perspectives article last year in the NEJM, Susan Okies suggested, “The primary care doctor is a rapidly evolving species …. it’s hard to say how primary care physicians will fit into emerging delivery models.”

Now, one year later, it seems that primary care is set to become central to the US healthcare development. Last week, The Commonwealth Fund released “Primary Care: Our First Line of Defense” where it endorsed the importance of strong primary care, and the medical home (similar to the traditional UK primary healthcare team) has become the model of choice. Indeed, a recent Commonwealth Fund blog indicates that private health plans in 49 states are testing this model and 19 states are involved in multipayer medical home pilots. The benefits to US healthcare will be familiar to many primary care academics from the research literature that shows improved quality of care together with patient and provider satisfaction. While it is seen as cost saving, this might not be entirely true as providing good quality primary care is not inexpensive. As Jeanne Haggerty and her colleagues point out in their BMJ editorial on the strength of primary care systems “health dividends cannot be obtained without financial investment, but the good news is that increased comprehensiveness is associated with a lower rate of growth in healthcare spending.”

However, recruitment is a problem in the US. In an editorial in JAMA, Mark Schwartz begins by pointing to a shortage of primary care services in the United States due to increasing demand and declining supply, and the projected figures that only 20% of medical graduates in 2012 will be practising primary care in 2015, highlights the problem. In the UK, we coped by creating an expanded primary care team but, involving non medical clinicians is seen in the US as disruptive innovation. And, even more recently, a survey of primary care doctors and nurse practitioners published in the NEJM, suggested that increasing their number and integrating nurse practitioners into primary care will not be easy. In JAMA this week, Joseph P Frolkis speaks about the benefit of the primary care team and the resistance by some older doctors because of their concern about the erosion of the individual relationship with their patients, but argues that teams can increase the opportunity for such “therapeutic connectivity” with patients.

Primary care has emerged from the shadows as central to development of universal and sustainable healthcare in the US. Uncritically adopting the UK model is probably not the best way forward. But, as this week’s NEJM editorial says: “Each country has strengths to be proud of and weaknesses that demand humility. Translating the best of each system need not mean transplanting the worst as well: a synthesis of the two systems could conceivably cover everyone, offer choice and competition, blend bottom-up creativity with top-down strategy, and integrate services so that patients get the right care in the right places.”

Domhnall MacAuley is primary care editor, BMJ.