Commentators Call For Health Reform To Revitalize U.S. Primary Care

In "A Lifeline for Primary Care," appearing in the June 25, 2009 edition of the New England Journal of Medicine (NEJM), lead author Thomas Bodenheimer, MD, professor at the Center for Excellence in Primary Care in the Department of Family and Community Medicine at UCSF, and co-author Kevin Grumbach, MD, professor and chair of the Department of Family and Community Medicine at UCSF, argue that a comprehensive federal initiative is needed to revitalize primary care in the United States.

In "A Health Care Cooperative Extension Service," in the June 24, 2009 edition of the Journal of the American Medical Association (JAMA), lead author Grumbach lays the groundwork for a primary care assistance program that would help primary care practices make improvements in their operations.

The pair of articles serve as a call for a primary care lifeline as part of health care reform, currently under discussion by both the legislative and executive branches of the federal government.

Bodenheimer's NEJM piece provides an overview of a three-point plan for federal legislation on primary care. The plan would reform primary care payment, invest in primary care infrastructure and organization, and attract more U.S. medical students into primary care by improving the work life of primary care physicians and by redirecting Medicare graduate medical education funds to primary care residency programs.

Current House and Senate health reform bills include many of the elements highlighted in the NEJM article. The bill drafted by the Senate Health, Education, Pension and Labor Committee includes a primary care extension program as described in the JAMA article.

"It has been proven over and over again that a solid primary care foundation to a health care system means better quality and lower costs," said Bodenheimer. "That is why Congress needs to strengthen primary care as a central feature of national health care reform," he said.

The authors warn that failure to address the shortage of primary care physicians as part of the health care reform package will lead to lower quality of care at higher costs. "The number of young physicians choosing primary care careers has dropped drastically; as a result, the U.S. faces a severe shortage of primary care physicians," said Bodenheimer. "Already, patients are having a difficult time getting primary care appointments, resulting in unnecessary emergency department visits that contribute to the high cost of care."

Both articles suggest a model for primary care revitalization modeled on a cooperative extension service like the one that helped transform farming in the U.S. in the last century. A nationwide Primary Care Cooperative Extension Service, if created and run by the Department of Health and Human Services as the authors recommend, would provide county-based health extension organizations to support primary care clinicians in the same way that the agricultural model supports family farmers, providing infrastructure for practice transformation through local learning communities, information exchange, and cross-fertilization of ideas among practices.

The cooperative extension model, using practice enhancement assistants or extension agents, would provide technical assistance in the implementation of infrastructure and business practice improvements including computerization and team-based models of care. The overarching goal of the extension service would be to create primary practice learning communities that share best practices and problem-solving strategies.

Grumbach concluded, "If Congress passes health care reform without strong provisions for increasing the numbers of primary care physicians and supporting those primary care clinicians already in practice, many newly-insured families will be unable to find a family doctor and costs will continue to escalate."