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Invited Commentary
Health Care Reform
January 28, 2019

Does Primary Care Add Sufficient Value to Deserve Better Funding?

Author Affiliations
  • 1Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
JAMA Intern Med. 2019;179(3):372-373. doi:10.1001/jamainternmed.2018.6707

Most advanced nations, such as those belonging to the Organisation for Economic Co-operation and Development, recognize and fully finance the central role of primary care in their health care delivery systems.1 They spend about 20% of their total health care dollars on primary care, support a 1:1 ratio of specialists to primary care physicians, and rank among the highest in population health status while keeping per capita health care costs relatively modest.1-3 This is not the case in the United States, where primary care accounts for only 7% of total health care spending and specialists outnumber primary care doctors by a ratio of 2 to 3:1,3 resulting in the world’s highest per capita health care costs and subpar population health status.2 The underfunding of US primary care has been suggested as one of the principal causes of the poor performance by our health care delivery system.4 In a landmark international study, Starfield and colleagues5 found that where primary care is available, per capita costs are lower, health status is better, and health disparities are fewer.

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1 Comment for this article
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Eric Harker, MD MPH MBA MS | Outpatient Primary Care
You make an excellent point that these results are given access to sorely underfunded primary care teams with very little support. What would care in the US look like if patients had access to empowered primary care teams with adequate time, training and resources to proactively manage complex care?

I spent 14 years in an excellent integrated health care system providing best in market primary care. Yet primary care made up less than 1/3 of the physician workforce and provided over half of outpatient visits. We had less than one team member per doctor (1/2 of an MA,
1/4 of an LPN, 1/8 of an RN), very large panels, inadequate time with each patient (20 minutes for a hospital follow up or new patient, regardless of age). I was constantly in a hurry and never felt I was able to provide the highest level of care that members deserve. Service was poor, burnout was high, and we were unable to control hospital and specialty costs.

I now work for a primary care focused medical group that leads with relationship based care. Appointments are 2-3 times as long, panels 1/3 the size, support teams 2-3 times as large and unmeasurably more empowered to care for members. Over 90% of our members advocate for our care, our costs are lower than competitors, quality scores are best in class, hospitalization and ER rates are low. Must be concierge care for the rich and healthy, right? No, in fact we care for Medicare and Medicaid members at the lowest price in the market, caring for elderly and low income members with heavy morbidity burdens.

Our approach is simple. Lead with primary care. Resource and empower primary care teams to care for members, manage complex disease, and improve the health and lives of our members.

It is a joy to practice every day.

Eric Harker MD MPH MBA MS
Iora Primary Care
Arvada CO