A Primary Care Home for Americans: Title and subTitle BreakPutting the House in Order

Dr Rushmore, a family physician, glances at her watch as she heads into the examination room to treat the last patient of the day. It is 6:15 PM. As usual, she is running more than an hour behind schedule. She is hoping that she can arrive at her son's high school baseball game in time to see the last few innings. That hope is quickly dashed as she realizes that the patient she is about to treat is Mr Heartsinque. From many years of having cared for Mr Heartsinque, Dr Rushmore knows that it will be difficult to complete the visit in only 10 minutes. Mr Heartsinque has poorly controlled diabetes mellitus and hypertension complicated by depression from his recent divorce and finds keeping track of his medications difficult. Most visits require time-consuming review of his complicated treatment regimen and discussion of his divorce and relationship with his children. Dr Rushmore is more conscious of the inadequacy of Mr Heartsinque's diabetic control since she started receiving periodic quality-of-care report cards from his health plan that list Mr Heartsinque as an outlier because of his many hemoglobin A_1c values above 10%. Today's visit promises to be even more difficult: Mr Heartsinque's prostate-specific antigen test result from his last visit showed elevated levels. Dr Rushmore will need to explain the implications of the test result and arrange a referral to a urologist for prostate biopsy. Undoubtedly Mr Heartsinque will bring up some new symptoms that he wants Dr Rushmore to evaluate.

As Dr Rushmore enters the examination room, she reminds herself of the satisfaction she gets from her primary care practice and how grateful Mr Heartsinque is about the time she spends with him. But she has to admit that the days do not seem long enough to do all that she has to do for her patients and that the challenges of primary care seem to be growing. She wonders whether she is either losing her stamina or trying to practice primary care in a health care world that demands new approaches.

Most people in the United States want a "medical home."¹ Primary care, through which physicians address a majority of patients' health care needs throughout a long time span,² was developed to serve as the medical home.

Although some nomadic patients prefer to navigate their way through episodic encounters with emergency departments and specialty clinics, the majority benefit from and desire a primary care home. In a survey of patients enrolled in California physician groups, 94% valued having a primary care physician who knew about all their medical problems. Most preferred to seek initial care for common problems from their primary care physician rather than a specialist.¹

The primary care home has several essential functions.^{2 - 3} Primary care offers first-contact care, the door patients can knock on to initiate getting help. Primary care is comprehensive, encompassing a spectrum of preventive, acute, and chronic health care needs. The primary care home is not temporary but provides longitudinal care with sustained relationships, a place where people know you. Also, the primary care home is a base from which other accommodations—specialists and other caregivers—are arranged. Abundant evidence indicates the benefits to patients and health systems of having a primary care home with these essential attributes.^{2 - 3}

Physicians such as Dr Rushmore work diligently to provide a good primary care home for their patients, yet primary care in the United States is showing increasing signs of strain because of heightened expectations for performance and shifting demographic and health care trends. Effectively responding to these problems will require fundamental redesign of systems for delivering primary care.

This article introduces a series on innovations in primary care and outlines why primary care is important, why it is under stress, and why its redesign is needed. This article is intended to provoke concern about the future of primary care and elicit creative ideas about the changes needed to sustain primary care in the 21st century.

As the 21st century unfolds, primary care is endangered.⁴ Strain is evident among primary care physicians. Most are stressed, some are exhausted physically and emotionally, and almost all are overwhelmed with crammed schedules, inefficient work environments, and unrewarding administrative tasks.⁵ The number of US medical school graduates entering family practice and primary care internal medicine residency training programs is decreasing, erasing substantial gains made in the 1990s.^{6 - 8} Anecdotes of early retirement among primary care physicians are common. Physicians often complain that they cannot spend enough time with patients. In California, 56% of primary care physicians surveyed in 1996 reported having sufficient time with patients, down from 80% in 1991.⁹ A 1997 survey of young physicians in major metropolitan areas nationwide found that only 32% reported having adequate time with their patients.¹⁰

Patients and physicians are communicating concerns about the state of primary care. Patients are less able to visit their primary care physicians when they need care,¹¹ often waiting weeks for an appointment. In a 1999 national survey of insured adults, 27% of people with health problems had difficulty gaining timely access to care.¹² Forty percent of visits to emergency departments are not urgent, many taking place because of an inability to obtain prompt primary care.¹³ Patients in one study consistently visited their primary care physician only 36% of the time.¹⁴

A third indication that the primary care home is unsound comes from evidence on clinical performance. Primary care physicians do not appear to properly manage chronic illness. Only 27% of patients with hypertension are adequately treated.¹⁵ Fifty-four percent of diabetic patients have hemoglobin A_1c levels above 7.0%.¹⁶ Only 14% of patients with coronary heart disease reach levels of low-density lipoprotein cholesterol recommended by national standards.¹⁷ Only half of tobacco users are counseled about smoking cessation by their physician.¹⁸ Primary care physicians are not solely responsible for these types of deficiencies and, in fact, appear to perform as well as do specialists caring for patients with common chronic illnesses.¹⁹ However, primary care physicians provide about 80% of visits for common conditions such as diabetes and hypertension.² Improvement in quality of care for these conditions must involve improvement in primary care.

Why is primary care endangered? One view attributes these problems to inclement external political and financial forces raining down on the primary care home. One such force is the traditional medical culture of the United States that exalts and financially rewards specialization. Managed care has been considered another major culprit in the troubles experienced by US physicians. Administrative hassles, challenges to clinical autonomy, and income reductions caused by managed care are souring some physicians on the practice of medicine. The managed care gatekeeper role has caused patients to be apprehensive about rationing of specialty care and financial conflicts of interest for primary care physicians. These factors must be addressed.

Other forces, more occult but equally potent, are also disrupting the primary care home. Advances in medical care, changing disease patterns, greater demand for clinical accountability, and evolving professional norms are creating heightened expectations for performance in primary care practice. These forces are not unique to the US health system but affect primary care practice throughout the developed world. It is clear that primary care in the United States is not designed to deliver the accessible, comprehensive, longitudinal, and coordinated care required by a 21st-century health care system. It is time for primary care to get its house in order.

Morrison and Smith²⁰ have termed the current predicament in health care "hamster health care": "Across the globe doctors are miserable because they feel like hamsters on a treadmill. They must run faster just to stand still. . . . But systems that depend on everybody running faster are not sustainable. The answer must be to redesign health care. . . . The result of the wheel going faster is not only a reduction in the quality of care but also a reduction in professional satisfaction and an increase in burnout among doctors."

The need for primary care redesign does not mean that other problematic factors affecting primary care should be belittled or overlooked. The United States needs to reduce income disparities between generalist and specialist physicians, allow primary care physicians to play a coordinating role without having the taint of gatekeepers rationing care, ensure patients' continuity of insurance coverage, and avoid needless administrative complexity. Yet even if these external storms miraculously ceased to buffet the primary care home, primary care would continue to face serious difficulties.

Nations with primary care–oriented systems tend to have better health outcomes and lower health care costs.³ Within the United States, states with more primary care physicians—but not specialists—have better population health indicators such as total mortality, heart disease and cancer mortality, and neonatal mortality.²¹ Continuity of care, more likely when care is provided by generalists rather than specialists,³ is associated with greater use of preventive services,^{22 - 24} reductions in hospitalizations,²⁵ and declines in overall costs.²⁶ Having a regular source of care results in better control of hypertension.²⁷ Generalists and specialists provide comparable quality of care at lower cost for a variety of conditions such as diabetes, hypertension, and lower back pain.^{19 ,28 - 30}

Even a system as specialty-centered as US health care relies heavily on primary care physicians. A recent study found that 87% of people in Massachusetts with a regular personal physician relied on a primary care physician.³¹ Half of all visits to physician offices are to family physicians, general internists, and general pediatricians, even though these physicians constitute only one third of the physician population.³² Most physician visits for prevalent, serious conditions occur in the offices of generalists: 85% for chronic obstructive pulmonary disease, 82% for hypertension, 68% for diabetes, 58% for stroke, 57% for coronary artery disease, and 56% for asthma.³³

Medical advances and social and demographic changes are creating greater expectations for primary care performance, challenging each of the core functions of primary care: comprehensiveness, accessibility (first-contact care), continuity, and coordination.

Providing comprehensive primary care has become exceedingly difficult. From preventive care to chronic care, there is far more for primary care physicians to do.³⁴ Within the past 15 years, 4 new vaccines (Haemophilus influenzae, hepatitis B, varicella, and pneumococcus) have been introduced into the routine childhood immunization series. Adult immunizations—hepatitis, pneumococcus, and influenza—came of age during the same era. A few decades ago, cancer screening was limited to Papanicolaou tests. Currently, screening for breast, colon, and prostate cancer constitutes routine primary care practice, with considerable patient education required to discuss the risks and benefits of prostate-specific antigen testing, the appropriate age range for mammography, and the appropriate colon cancer screening technique: stool hemoccult, sigmoidoscopy, or colonoscopy.

Management of many illnesses has become far more complicated. Care for patients with diabetes illustrates growing demands in chronic illness care. An aging, more sedentary, more obese US population has developed a greater prevalence of type 2 diabetes mellitus. More aggressive screening combined with less restrictive criteria for diagnosing diabetes has resulted in earlier detection. Until recently, lack of convenient methods for home blood glucose level monitoring and lack of evidence about the effectiveness of tight glycemic control made loose control of blood glucose an acceptable practice via rudimentary monitoring of urine glucose and ketone levels. Before the 1980s, routine hemoglobin A_1c testing did not exist, much less guidelines for periodic testing (in addition to annual dilated eye examinations, blood pressure control, lipid-level management, and measurement of urine microalbumin levels). In the pre–managed care era, a nonketotic patient with hyperglycemia could spend several days in the hospital for treatment and diabetic education, in contrast with the current expectation for intensive treatment and teaching in the ambulatory and home settings. An aging population with a greater prevalence of chronic disease means that physicians often must manage multiple illnesses in the same patient.

The scope of primary care practice has also expanded in the face of growing medicalization of social problems. Depression and other forms of mental illness are increasingly recognized as benefiting from appropriate diagnosis and medical treatment. School problems that once earned only detentions now generate queries to the primary care physician about attention-deficit disorder. Primary care physicians are expected to screen patients for substance abuse, domestic violence, and HIV (human immunodeficiency virus) risk behaviors. Even snoring is no longer considered a benign annoying behavior but must be evaluated as a possible symptom of sleep apnea, with its attendant complications of arterial and pulmonary hypertension.

Higher standards for comprehensiveness of care create tensions for accessibility. The traditional primary care practice was organized to respond to acute and urgent medical care problems. Primary care physicians routinely experience the "tyranny of the urgent": pressure to relieve symptoms, cure disease, and diagnose potentially serious conditions crowds out time for preventive care and chronic illness management.³⁵ Attempts to allot scheduled time for health maintenance and chronic care visits reduce physician availability for acute and urgent problems.

Primary care physicians must also be aware of novel forms of communication technology. Also, patients are less tolerant of long waits, inconvenient office hours, and a system designed around provider, rather than patient, prerogatives. First-contact care no longer exclusively refers to the conventional office visit. The computer-savvy sector of the population seeks access through e-mail and the Internet, raising new accessibility obstacles for primary care physicians. Although these trends may ultimately lead to greater efficiency and creativity in the medical encounter, destabilization of traditional modes of operating will be difficult for many physicians.

Social trends also place strains on continuity of care. The growing complexity of health care organization has created larger practices, displacing the archetypal solo primary care physician who personally attended to each patient during every visit. A new breed of primary care physicians demands a balance between professional and personal life, bringing into question the 60- to 70-hour workweek common among prior generations. Women, who compose a growing proportion of primary care physicians, are more likely than their male counterparts to work part-time and take time out for child rearing. Young male physicians may also opt for more part-time work.³⁶ The result is a primary care practice setting with fewer full-time physicians, which challenges traditional expectations about face-to-face continuity of care between patient and physician.

The complexity of health care also places greater demands on coordination of care. For example, the burgeoning home health care sector requires primary care physicians to coordinate home-based services in addition to office and hospital care. An increasing per capita rate of prescriptions generates more information to integrate into primary care management plans.³⁷ As specialty care offers newer and more complex interventions, primary care physicians are expected to master the best place to send patients with a variety of conditions. After reading their local newspaper's comparison of coronary artery bypass graft surgery death rates, hospital by hospital, cardiac patients may rightfully expect to be referred to a high-volume, low-mortality facility.³⁸ Complicating these trends, managed care systems may dictate which specialty, home care, and hospital facilities are allowed for which patients.

One more feature of the primary care home is showing signs of stress from rising expectations. The Institute of Medicine's refined definition of primary care emphasizes that primary care must be accountable.² Health systems expect primary care physicians to measure and document their standard of care, meet explicit standards for clinical performance, and participate in quality improvement processes. Health Employer Data and Information Set performance measures are heavily weighted toward such primary care items as preventive services and chronic disease management. Many primary care physicians routinely receive report cards indicating whether their practice falls below some benchmark on clinical indicators and patient satisfaction ratings. Managed care organizations may also profile the cost patterns of primary care physicians, including accountability for expenditures as another burden for primary care physicians to shoulder.

The clearest symptom that these combined factors are creating stresses in primary care practice is the frequent complaint about lack of adequate time during office visits. As noted earlier, growing numbers of US primary care physicians believe that they cannot spend sufficient time with patients. Physicians in other nations voice similar complaints.²⁰ Paradoxically, there is no evidence that the actual length of office visits in the United States is getting shorter. Between 1989 and 1998, the mean length of a primary care office visit in the United States increased from 16.3 to 18.3 minutes.³⁹ What explains this paradox of longer average visit times and physician complaints of less adequate time? One explanation is the increasing distractions that cut into meaningful patient care time. The average family physician or internist in the United States wastes 40 to 50 minutes each day on managed care administrative hassles.⁵ However, the clinical demands on primary care physicians during the typical office visit are also increasing.⁴⁰ In the face of heightened expectations for comprehensiveness, accessibility, coordination, continuity, and accountability in primary care practice, a decade's addition of 2 minutes to the average visit time is experienced as losing rather than gaining ground.

Practicing primary care has always been hard work. Although the exigencies facing primary care today are not unprecedented, they are shaking the foundation of primary care with extraordinary intensity. In a society with heightened expectations for health care, the medical profession is being challenged to demonstrate that it can provide excellent service.

If primary care physicians are to step off the hamster treadmill, major innovations in the organization and practice of primary care will be required. Managed care has failed to catalyze fundamental changes in how health care is delivered, leaving intact irrationalities and inefficiencies. New ideas are needed.

First and foremost, primary care physicians need a new environment in which to work, a climate less permeated with stress and overwork. Second, this new environment must be intertwined with systems of care that improve access and quality while they relieve physicians' workload. Third, and most difficult, these changes must take place without major increases in total health care costs, requiring an extensive redistribution of health care dollars from institutional care to a redesigned primary care home.

What are the alternatives to refurbishing the primary care home? What if entry of new medical graduates into primary care specialties continues its downward trajectory, leading to a dearth of generalist physicians? One alternative is a system of care that relies almost exclusively on specialist physicians. The 50% of chronic disease patients with more than one chronic condition would need to participate in separate disease-specific programs rather than rely on an integrated primary care approach. Patients would be responsible for initiating and arranging preventive care services through direct-access mammography and colonoscopy centers, pharmacy-based influenza immunization sites, and other preventive care venues. Comprehensiveness, coordination, and care of the whole person would not be dominant values of this system.

Another scenario entails physicians vacating the primary care home to nonphysician clinicians. An exhausted, undercompensated cadre of primary care physicians would retire and be replaced by nurse practitioners and other nonphysician clinicians, all of whose numbers are increasing. A vestigial primary care physician workforce would attempt to bridge the services provided by nonphysician primary practitioners and the biomedical specialist physicians. The new generation of primary care clinicians would struggle with the same irrationalities and dysfunctional systems that drove physicians from primary care practice.

Neither of these scenarios is satisfactory. All health systems need a sturdy primary care home. Although physicians will not play as dominant a primary care role as they once did, future care models configured around multidisciplinary teams will require their strong and continued presence.

A system based on primary care is essential, but for primary care to survive and flourish, it must undergo drastic change. In the words of Donald Berwick, "We are carrying the 19th-century clinical office into the 21st-century world. It's time to retire it."⁴¹