The Need for More Primary Healthcare

By Dennis Boone

It’s a generally accepted principle of health-care bean-counting that the best way to control the costs of care is to prevent disease or illness, or failing that, catch them at their earliest stages. And that the most efficient tool for fulfilling 

“For groups that have a policy like that, we see 75-85 percent of employees participating, getting that annual physical exam. Some employers are giving up $60 or $70 a month in terms of a discount if people comply, so they’re real dollars.” — Polly Thomas, president, CBIZ Kansas City

those two missions rests with the kinds of care that patients receive with primary-care physicians, especially those aligned with patient-centered medical homes and other more whole-person views of patient care.

And yet:

  •  The Centers for Disease Control’s National Health Interview Survey for 2014 showed that 17.3 percent of the adult population in the U.S.—more than 41 million people—didn’t see a physician of any kind in the previous 12 months. 
  • Among that group, nearly one in three hadn’t seen a doctor in at least two years.
  • And one in seven hadn’t seen a physician in the previous five years. Five.

The cost implications of those figures are obvious to health policy-makers: As far back as 1994, a paper published in the medical journal The Lancet estimated that between 75 and 85 percent of all medical patients could be treated with primary care alone; according to the CDC, however, that ratio is closer to a 50-50 split between the lower-cost primary care and the pricier specialty treatments. Primary care visits in 2014 accounted for 53.2 percent of physician contacts, while specialists saw 46.8 percent, agency figures show.

The Kaiser Family Foundation, which specializes in health-care policy research, estimated last fall that despite the ACA’s contribution to driving down the number of uninsured people to historic lows, 28.5 million people remained uninsured by 2015. Health insurance, the foundation said in that report, “makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy they are. Uninsured adults are far more likely than those with insurance to postpone health care or forgo it altogether. The consequences can be severe, particularly when preventable conditions or chronic diseases go undetected.”

Certainly. But for the insured, the question is, why? Why would rational people, knowing the costs of deferred care will exceed costs of immediate or preventive care, delay that care? Perhaps the most obvious answer, insurance professionals and providers say, is because they expect that someone else will eventually pay.

And they’re right: It’s Americans paying health-insurance premiums, it’s hospitals writing off more uncompensated care than would otherwise be necessary, and it’s physicians—especially private-practice physicians—whose reimbursement rates for federally-subsidized care are constantly being squeezed by government bean-counters.

Closer to home, those CDC statistics also show a major disparity between the use of primary-care physicians in Kansas and Missouri. While Kansas residents hew to national norms in terms of usage, Missouri ranked fourth-worst among states for 2012, with 39.3 primary-care visits per 100 residents, dramatically lower than the national figure of 61.4 visits per 100.

That last figure is particularly mystifying, given that the more rural nature of Kansas creates barriers to access for many in farther-flung areas. 

But even after accounting for access issues, says Gina Ochsner, director of network development and regional relations for Topeka-based Stormont Vail Health,
“I think people still have common misconceptions about primary-care medicine. Many still assume that specialty care is higher quality care than that provided by a generalist.” And even though Obamacare in practice is into its fourth year, she said, “many are still not aware that ACA eliminated that out-of-pocket expense on their health plan for preventive services. There’s still a strong lack of awareness and education about all of this.”

Because data aggregation at the federal level runs years behind real time, it’s hard to say just how much the utilization figures may have improved as Obamacare has been implemented in stages since 2014. Clearly, there are signs of higher usage, especially among the groups that previously were least likely to see a physician because of out-of-pocket costs—the poor and lower middle classes.

But if it’s inching up, it’s from a bar set awfully low.

With statistics on percentages of people aligned with a primary caregiver, says Polly Thomas, president of CBIZ,  “it used to be, if we looked at a block of business across the board, the numbers would be lower than 50 percent—in some cases, 25 or 35 percent that actually had and complied with preventive-care services.”

For a variety of reasons, she said, those numbers are ticking up. “The biggest factor may be that many employers now offer further discounts on insurance if their employees get annual preventive exams,” she said. “For groups that have a policy like that, we see 75-85 percent of employees participating, getting that annual physical exam. Some employers are giving up $60 or $70 a month in terms of a discount if people comply, so they’re real dollars.”

That’s some of the anecdotal early evidence that one part of the Affordable Care Act generally considered a success—physician office visits covered by insurance—is meeting its goal of shifting responsibility for control of health-care costs onto patients.

“In the past, I would say that cost did prevent many individuals from receiving preventive-care services, and the ACA did remove that cost barrier,” says Ochsner.

But if the nation is ever to successfully attack health-care costs at the margins, it’s looking at major lost opportunity if one in six adults hasn’t been to a doctor in the past year.

“There are still a lot of folks who do not have a primary location to see a doctor,” said Dr. Gregg Laiben, vice president and former medical director for Blue Cross Blue Shield of Kansas City. “When something does happen, they don’t have a medical home with which to evaluate, assess and treat the problem.”

One thing missing, he said, was a mindset that encouraged care among adults the way society generally regards the need for care with children. “We identify a primary care doctor to take care of their needs for immunization, prevention, checking their growth and following things to make sure children are on the right health track and getting great nutrition,” Laiben said. “We need a similar approach with adults.”

The biggest reason for that is because of the way the body ages. Progressing from early adulthood into mid-life, the natural tendency is development of chronic medical conditions, especially heart disease, high blood pressure, diabetes and high cholesterol. Without regular preventive visits, Laiben said, “by the time you identify a problem, the damage has already started, and it’s damage that doesn’t need to be done.”

But beyond patient behaviors, some of the challenge facing providers is struc-tural. For one, the nation has, in global terms, flipped the ratios of primary-care physicians-to-specialists. In the U.S., more than 60 percent of practicing physicians are specialists. That’s attributable, health professionals say, to multiple factors: the development of technologies that expand diagnostic and therapeutic options available to specialists.

Another factor is the disconnect between patient, provider and payer. Patients who aren’t responsible for the bulk of their costs of care are more likely to seek out doctors offering more sophisticated, and more expensive, treatment. Finally, there’s a national shortage of primary-care physicians—one that will get considerably worse over the next decade—in part because it’s harder to make a living as a doctor and cover costs of malpractice insurance if you’re trying from a primary-care setting.

Whether by market rates or public-reimbursement levels, specialists tend to earn more. So it shouldn’t be surprising that someone going through a decade or more of medical school, residency and fellowship would be drawn to more lucrative career paths. That, too, is something that moves in cycles.

“The ACA definitely built in some ideas about trying to utilize primary care to improve outcomes, improve holistic care, and control costs, or at least rein in some of what folks see as excessive healthcare costs,” said Allen Griener, vice chairman of the Department of Family Medicine at the University of Kansas Medical Center. “But that’s a return to ideas that have been around a long time. When I trained in medical school 25 years ago, there was a push to have more primary care folks and have primary care quarterbacking and gate-keeping the system to control cost. That derailed in the late 1990s in some ways, but it’s coming back now.”

The challenges to chipping away at unaligned populations, he said, include consumer resistance. “A lot of people don’t see the value in some of these ACA features,” Greiner said. “Some of that is the value of primary care in general, or seeing the whole thing as a government push to interfere in the system. I do think there is a lot of potential to do things a little differently, with a little more prevention focus.”

From the perspective of insurers, Laiben said, “we want two things to happen: We want high-quality care, so that if a condition is present, you treat it and control it. We also want that prevention aspect and monitoring. From a patient perspective, if you can catch something early, it leads to a better quality of life, a longer life. It’s a wise spend of dollars.”

And yet, as Ochsner noted, challenges remain that are going to be difficult to solve. For one, “people are still reluctant to go to a physician when they feel fine,” she said. 

“Research shows that those preventive services can save lives and do improve health overall, so it’s important to identify those illnesses early. We still have a long way to go in educating people about the importance of that care, and removing obstacles to access. Whether it’s with expanded hours and locations, or different methods to get care to people, as with telemedicine, there is a lot
of room for improvement.”