Primary Care Advocacy Tool Kit

POLICY ANALYSIS

Why is Primary Care not the foundation of our health care system?

Anthony L. Schlaff, MD, MPH
Director - Futures Project
Director, MPH Programs
Department of Family Medicine and Community Health
Tufts University School of Medicine
136 Harrison Avenue
Boston, MA 02111
anthony.schlaff@tufts.edu
(617) 636-6584

Evaluation of health care policy in the US has focused on three main attributes: cost, access, and quality. In other industrialized countries, equity is also often included as a basic, desirable attribute of a health care system. These attributes are often understood as affecting each other, often competitively, so that attention must be paid to the affects on all attributes when policies are proposed to improve one particular attribute.

In the US, however, the recent policy debate has been almost completely about cost and financing. Health care is so expensive that the need to control costs has dominated the discussion at the expense of discussions of access and quality. In addition, an anti-government ideology has pre-dominated which assumes that governments role, if any, should be confined to establishing payment mechanisms. An unintended consequence of this ideology directed at the role of government is that serious discussions of access and quality do not happen at all until the major decisions about financing and cost containment have been fixed, with the result that assumptions about what the care should be and how it should be delivered go unexamined, and access and quality issues become subsumed under cost discussions.

Furthermore, even when the discussion had included access and quality, these attributes had been presented in almost purely economic terms. Access does not mean only ability to pay, and quality does not mean only measures of consumer satisfaction that drive enrollment decisions, but there is little evidence in policy discussions that broader meanings of access and quality are discussed.

Underlying all discussions about health care is the assumption that health care is a social good that all people desire for the purpose of improving their health, and thereby their lives. If health care is indeed such a social good, then discussions of quality should go beyond measures of patient satisfaction for the purposed of marketing.

The most interesting issues raised by papers addressing the future of priamry care (unpublished) have to do with the disconnect between providers and users of care. While patients want a system that has the attributes of primary care: access, accountability, coordination, comprehensiveness, and continuous (i.e. with a relationship), patients mean different things by these terms than providers do. It is also clear that, while the policy discussions focus on cost and financing, the content and context of care has been changing in ways that run counter to what patients want, and that run counter to primary care models. Despite this, patients do not articulate a desire for a primary care system...in part because of the warped meaning of the term as created by managed care, and in part by the failure of primary care providers to adapt and meet people's needs.

How would one summarize what most patients want from health care? Based on the work of Cary et al (unpublished), they want more time and communication with their providers. They want attention to social and emotional aspects of care. They want assurances that their providers are making decisions based on the best care, free of financial constraints. They want efficiencies in access to care: specifically they want human beings on the telephone, short waiting times, and the availability of walk-in appointments. They want a system that helps with transitions – in particular they want to feel that the various providers are working together on their behalf to create holistic care. They want a system that feels open and does not present roadblocks to the care they receive.

It would be one thing to say that our system is failing to provide what patients want. What is more striking is that, based on the listing above, it appears that over the last decade our health care system has been working deliberately to remove what people want. Managed care and provider productivity has actively worked to shorten and restrict visits. This is done in the name of cost saving, but it should be noted that no other country in the world attempts to save health care dollars in this way. Ironically, it appears that these attempts have not shortened visits, but have increased the perception that time is restricted, and thus have increased dissatisfaction with the system. Globally, visits to physicians are longer and more frequent, and costs are less. This is because the escalating costs of the health care system do not reside in the time to human beings spend together – but in other costs – of technology, administration, pharmaceutical costs, and profit. It seems we are working most effectively at restricting the one resource – time for human contact – that is both important and not necessarily that expensive.

The system is deliberately moving away from patient desires in other ways as well. As care gets defined as a commodity, quality becomes equated with clinical outcomes based on variables such as training of care giver, technical procedure, medication prescribed, and diagnosis made. While these variables are certainly important, they are reductionist, in that they reduce a care visit to the biomedical problem and the specific technical interventions designed to treat or cure. But if most patients go to care givers for care - for reassurance, advise, prognosis, symptom control, or just an attentive ear - then none of these measure will capture the purpose, let alone the quality, of the visit. Patient satisfaction is measured, to be sure, but often only in reference to the reductionist measures that may well miss the underlying reasons for that satisfaction or lack thereof.

A third way that our system is deliberately moving away from what patients want is in failing to provide accountability to the patient for their care, free of real or perceived constraints based on financial incentives or allegiances to parties external to the patient-provider relationship. Our system has deliberately sought to hold providers responsible for reducing the cost of care, and patients know and believe this. The decline in trust between patients and providers has become palpable and may in fact have resulted in increased costs, as harried providers seek to deflect patient distrust and concern by ordering the expensive diagnostic battery (thus making it possible to complete that visit in 15 minutes, without the need for a detailed history that might give the diagnosis, a better treatment, and better outcome). This decline in trust, and the awareness of the intrusiveness of the third party payer, may also be the key to explaining the paradox that, while visit times may be about the same, many patients and providers believe that they have dramatically shortened.

Finally, the competitive marketplace has taken from patients one other attribute they want from their system – a sense of holistic structure to the relationships among their caregivers, so that their care can be coordinated from a clinical perspective, so that there are no roadblocks to necessary or desired referrals, and so that transitions from one provider to another can be made with a minimum of hassle and a maximum of timely communication.

How could this happen? Why would health care move deliberately in the opposite direction from what people want? How could this happen in a competitive marketplace where presumably the consumer is king, and where providers who do not provide what is wanted are punished by losing business.

First, it is clear that health care is not a commodity. In every nation of the world, government is heavily involved in the regulation and financing of health care. Providers wield substantial monopoly power, and they act as both the advisors and providers of services. Relative to providers, consumers know very little about health care. In addition, there are externalities. The health or illness of an individual may have direct or indirect economic impact on other individuals in the community. This is why most societies treat health care as a social good.

Not only is the “product” of health care not a commodity, but the health care marketplace is not a place where consumer choice can be exercised. First, the power of decision is exercised yearly when people select their health plans. This selection is done in the abstract, at a time when people are probably much more sensitive to price, and insensitive to issues of quality and access, then they would be at a hypothetical future time when they are sick. Most people want this separation, so that they are not forced to consider economic consequences in seeking health care at a time of illness and vulnerability. In addition, there are two intermediaries between patients and their providers: the purchaser of insurance and the insurer. Both these parties have interests different from the patient and reduce knowledge and choice by patients in a number of ways.

The place where people choose what kind of health care they get has been, and always will be, in the political arena. Here, interest groups and politicians have engaged in distortions of language, distortions of interpreting the popular will, and distortions of explaining the effects of health care policy. It is this political arena that our society chose corporate managed care over federally regulated and financed care in large part due to advertisements by insurers (using the characters of Harry and Louise) warning that the government would limit our choices. When did the dialogue occur about how private corporations would likewise limit choices?

In effect, we may have a system that combines the worst features of the market and a regulated system. The market creates incentives and constraints for purchasers, insurers, and providers to provide services and structures that are in their interest but that are not necessarily in the interest of the patients themselves, as the patients have virtually no market power except at times when their decisions are apt to be skewed. Because there is price competition affecting everyone but the patient, there is a potential incentive to cut costs at the expense of the interests of the patient. Quality (both effectiveness and satisfaction) and access have little or no role in the economic decision making that determines which services are offered. Even as this flawed market operates, the paper by McKinney et al makes clear that health care has been highly influenced by government regulation and interventions, but again in ways that may have directed the development of services away from desirable models of primary care.

To the extent that regulation or marketing require attention to quality and access, these are measured only within the existing financial services. Patients may want more time with their provider, but satisfaction is measured only according to which 15 minute visit is more acceptable than another. It would be as if the furniture market decided that $50 was the maximum they would charge for a sofa, then designed sofas they could afford to make for such a price, and then attempted to market them, finally coming to one of two conclusions: that people don’t want sofas or that the one with the plywood cushion is as comfortable as a sofa can get.

Clearly, this is no way to design a service. Cost constraints must be taken into account of course, but only after attention has been given to what the service or product should be, and what all the potential tradeoffs between the ideal and the price can be. In the United States, we have failed for the last 10 years to discuss what we want from our health care system. Because health care is not a market product, because of the tacit agreement that it should be provided through a system of social insurance, and because of the heavy public investment in care, such a discussion must happen if the U.S is to get reasonable care. The market experiment has not failed – rather it was never started and never can be. We have simply pretended to have such an experiment and in the meantime have failed to have the conversations that will lead to a political consensus, or at least a decision.

Critics of primary care note that patients do not choose such care. If, however, we understand that health care choices are shaped by limited and flawed information and access, and by biases built into the available economic and service delivery system created without recourse to any true measure of community choice, then we can avoid a mistaken inference from the observations about health care consumer choice. No one would assume that a customer who chose a ripe apple over a rotten peach prefers apples as a general rule. In the same way, we cannot assume that patients in the U.S. prefer the specialist model, which has been carefully crafted for them, over a model primary care system. The primary care that has suffered an apparent rejection is an under-funded and underdeveloped system created by a false market and misdirected policy.