The Primary Care Solution

"President Obama has pledged that reform must produce both universal coverage and major cost savings," writes Dr. Thomas J. Gates of Lancaster. "Understandably, we are skeptical." How can covering more people not drive up health care costs? By emphasizing primary care much more than we do now. "Without exception," says Gates, "regions and countries with the best medical outcomes have built systems with good access to primary care medicine."

Gates, who is a family physician and on the faculty of the Family Medicine Residency Program at Lancaster General Hospital, described his views in the August 30 edition of the Lancaster Sunday News.

"With overall costs having doubled in the last 10 years, and projected to double again in the next 10, the current chaos is simply not sustainable," wrote Gates. "The market system deals with this economic reality the only way it can:  by pricing more and more people out of the access to health care.  From the data on personal bankruptcies, to our comparative disadvantage in world trade, much of our current economic malaise is rooted in the high cost of U.S. health care.

"America, we can do better than this!"

How?  Gates describes how the U.S. medical system gradually has come to emphasize specialist care rather than primary care.  He cites a variety of reasons for this including the high cost of a medical education, the tilt in reimbursement rates toward specialty care, and the fact that specialists routinely double and triple the salaries of primary care physicians.

How would emphasizing primary care bring down costs while improving medical outcomes?

"Consider which of the following represents 'better' care:  $50,000 emergency bypass surgery, or years of attention to controlling hypertension and cholosteral (perhaps preventing the need for bypass surgery)?  A state-of-the-art amputation of a gengrenous leg, or years of meticulous control for diabetes (which can prevent the need for the amputation)?  Months of ICU treatment for a severely premature infant, or access to routine prenatal care (which decreases the rate of premature births)?  A tortured last few weeks of life undergoing increasingly fultile ICU care, or a dignified and peaceful death at home under the care of hospice?  In each pair of choices, both will always be necessary, but the U.S. health care system seems to 'specialize' in the first, while neglecting the second.  From a system-wide perspective, more is not better; more is simply wasteful."

Gates praises HR 3200 - the health reform bill currently pending before the U.S. House of Representatives - for beginning the process of re-emphasizing primary care.

"If we are serious about cost control, ultimately we will need to challenge the special interests and change the way physicians and hospitals are reimbursed.  Simply put, the current fee-for-service system rewards excess.  Real change will come when we find ways to pay doctors and hospitals to manage chronic diseases and prevent complications, rather than the current system of rewarding episodic, uncoordinated, and often wasteful care."