William Cayley: Continuity over efficiency

bill_cayley_2It has become fairly clearly established that a strong primary care system is associated with better overall health for a society and a more equitable distribution of health in the population.

A recent modeling study in the Annals of Family Medicine, which evaluated the “primary care paradox” (lower levels of evidence based care for individual diseases, but healthier populations, less use of resource, and reduced levels of health inequality), suggests that this is because primary care leads to increased disease prevention visits and reduced illness visits in disadvantaged neighborhoods. Other research has suggested that individualized management of new symptoms and chronic conditions may be the key advantage of primary care.

The increasingly pressing question as we move further and further into 21st century medicine, especially in high income countries with their Pandora’s jars of high-tech testing and multispecialty referrals, is how to foster and sustain such continuity.

A recent pair of editorials in the New England Journal of Medicine debate the value, or lack thereof, of the “annual physical” for promoting the continuity of the physician-patient relationship. While the pros and cons of this discussion are illuminating, and raise questions about the place of evidence vs relationship in determining what healthcare services should be “covered,” true promotion of continuity of care requires a more fundamental change in the way we structure healthcare services and payment.

• We need to promote scheduling of physicians’ time so that when a patient is sick, s/he can see their primary physician, rather than being referred to an “acute care” or “urgent care” clinic—even an “urgent care” clinic that is part of a larger system is still not the same as seeing one’s own physician. (I’ve posted a few thoughts on this sort of scheduling previously).

• We need to support the provision of continuity of care across settings through family doctors, GPs, and other primary care specialties. The American shift of primary care physicians away from hospital care, with in-patient care instead provided by hospitalists, undermines continuity and may, in the long run, be more expensive.

• Electronic—and sometimes “asynchronous”—care is now in vogue with the growth of “web based” society, and now some American insurers are offering “online” visits with a remote physician to address acute illnesses. Rather than promoting visits with an unknown, remote physician, insurers wanting to participate in web based medicine should be promoting the use of electronic remote visits with a patient’s own primary care physician.

Admittedly, some of these problems and solutions may be uniquely American—and may sadly be beyond the reach of our currently fragmented kaleidoscope of healthcare systems in the US.

However, if we are to genuinely realize the full potential and benefits of primary care, we need healthcare systems that, in both their service structures and their financing, prioritize continuity rather than efficiency.

(Who knows, in the end continuity may be more efficient too!)

William E Cayley Jr practices 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.

Competing interests: “I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.”