About three-quarters of Americans have a primary care physician. Having a primary care doctor is associated with better health outcomes. As we have previously noted, Americans tend to trust their primary care physicians more than most other sources of healthcare information.
All of this should mean that it might be a wise move to extend primary care to more people and to ensure that primary care doctors have enough time to spend with their patients to take advantage of that trust and help them navigate the many pathways to optimal health outcomes.
In fact, however, according to a recent report from the Commonwealth Fund, the U.S. is failing at providing high-quality primary care compared to other high-income countries. The report is based on surveys the Fund conducted in 2019 and 2020 with primary care physicians in the U.S. and 10 other high-income countries. Among the findings are:
· U.S. adults have nearly the lowest likelihood of having a regular doctor or place to go for care (Sweden was slightly lower).
· U.S. adults are the least likely to have a long-standing relationship with a primary care provider (43% versus 71% of adults in the Netherlands or 57% in Canada).
· U.S. adults are least likely to be able to see a primary care provider after regular office hours
· Primary care physicians generally do not screen their patients for social needs, but here U.S. doctors are the most likely to do so (30%). The authors of the report speculate, however, that this may be because the U.S. has the poorest social services networks for its citizens, creating a greater need for such inquiries. Only Canadian primary care providers are more likely to have social workers in their practices (42% versus 37% in the U.S.).
· Only one-third of U.S. primary care physicians have mental health providers in their practices. This is about midway among the countries in the survey, with nearly all practices in Sweden and the Netherlands having mental health providers in their practices, but almost none in Germany, Switzerland, or Norway.
· Only half of U.S. primary care providers report adequate levels of coordination with specialists and hospitals about changes in their patients’ care plan, putting the U.S. near the bottom in this category. Similarly, only half of U.S. primary care providers are notified when their patients are seen in an emergency department, compared to 85% and 84% in New Zealand and the Netherlands, respectively.
Overall, then, the report makes clear that the U.S. is doing a poor job at primary healthcare. Importantly, the report notes that these shortcomings in U.S. primary health care are not distributed evenly but “affect predominantly Black and Latinx communities and rural areas, exacerbating disparities that have widened during the COV ID-19 pandemic.”
What Do People See Primary Care Providers For?
An average visit with a primary care physician lasts 18 minutes. According to a Mayo Clinic study, these are the top ten reasons for those visits:
- Skin disorders;
- Osteoarthritis and joint disorders;
- Back problems;
- Cholesterol problems;
- Upper respiratory conditions, excluding asthma;
- Anxiety, depression, and bipolar disorder;
- Chronic neurologic disorders;
- High blood pressure;
- Headaches and migraines; and
Now let’s look at the top causes of preventable premature death in the U.S. This list is topped by tobacco smoking and includes obesity, alcohol use, hypertension, some infectious diseases for which vaccinations are available, firearm injuries, and suicide. In the 18 minutes that a primary care doctor has with a patient, how much time is spent dealing with these preventable causes of premature death? Take cigarette smoking, for instance. We know that relatively brief primary care interventions can have a significant effect on increasing the chances that a smoker will quit. The same is true for harmful alcohol consumption. Primary care physicians may themselves be surprised to learn that their paying attention to their patients’ weights can influence obese patients to attempt weight loss, a practice that may be helpful for many people with high blood pressure or diabetes. We can also wonder about the potential impact on mental health and suicides if more primary care practices had mental health practitioners within them.
Do primary care physicians have time to talk to patients about their lifestyle and behavioral issues? Do they keep careful track of their adult patients’ vaccination status? When a patient circles “yes” on the pre-visit form about cigarette smoking, does the doctor recognize that even a few minutes spent talking about options for quitting can save more lives than almost anything else the doctor can do?
U.S. Primary Healthcare Needs an Overhaul
It is clear we need to fix the primary healthcare system in the U.S. Right now, it is a disorganized system that disadvantages people of color. It is also unprepared to deal with the factors that are clearly responsible for most people’s adverse health outcomes. Treating rashes, upper respiratory infections, and backaches is important, but primary care clinicians could have far more impact on the public’s health if they also dealt with tobacco and alcohol use, obesity and lack of exercise, and vaccine hesitancy. Furthermore, their practices would become far more impactful if they included mental health providers to deal with common psychiatric conditions like anxiety disorders and depression and social workers to help with the social determinants of health like food and housing insecurity.
The U.S. clearly has a long way to realize any of these goals. As Kevin Grumbach and co-authors wrote in their September 2021 New England Journal of Medicine article “Revitalizing the U.S. Primary Care Infrastructure”:
More than half of office visits in the United States are to primary care clinicians, yet primary care physicians make up only 30% of the physician workforce and are supported by only 5.4% of national health expenditures, and research on primary care garners just 1% of federal agency research awards.2 One in five Americans live in a federally designated primary care Health Professional Shortage Area. Primary care physicians earn 30% less than other physicians, on average, and they have among the highest rates of physician burnout.3
In its sweeping 2021 report on rebuilding the U.S. primary health care system, The National Academies of Sciences, Engineering and Medicine noted that “The value of primary care is beyond dispute” but at the same time “this foundation remains weak and under-resourced.” Clearly, the first order of business in repairing our crumbling primary healthcare system is to fund it adequately. This is perhaps easier to do in countries that have rational, single-payer healthcare systems (as is the case in all high-income and many middle- and low-income countries, but not the U.S.). What we need, and what the National Academies endorse, is a major rethinking of how we finance medicine.
Right now, the highest paid medical specialties are mostly surgical. Primary care physicians are way down on the list. If someone does choose a career in primary care medicine, they will be faced with having to see large numbers of patients for short periods of time, day in and day out. There will be endless hours logging all these patient encounters into the electronic health record (EHR), most of which gets done after hours and without compensation. No wonder we have a shortage of primary care physicians and those that do enter the field suffer high rates of burnout. The first order of business, then, in repairing the primary care system is to compensate primary care providers better and make primary care a desirable medical specialty.
Next, we must compensate those primary care practices to be able to spend enough time with patients to accomplish a public health mission: the prevention of disease. That means not only asking patients to fill out questionnaires about their health and habits (many of which seem never to actually get read by any health professionals) but having the time to actually deal with the responses. If someone smokes, is drinking alcohol excessively, is eating a high sugar diet, or is hesitant to have a flu vaccine, the doctor or another health professional in the office needs to address that problem using evidence-based approaches. The healthcare system must be prepared to pay people to do that.
All of this will require training primary care physicians, nurses, social workers, and other healthcare providers in a new paradigm of care, one in which attending to the real causes of diseases and the impediments to successfully overcoming them is of paramount importance. For example, primary care physicians must be trained in techniques like motivational interviewing and other evidence-based approaches to helping patients with substance use issues. A mental health clinician trained in cognitive behavioral psychotherapy for depression and anxiety should be part of every primary care practice. Patients who need to lose weight or exercise more should be given help, encouragement, and follow-up support by people they trust, that is, by their primary care doctor. Primary care offices should have social workers who can assist patients in getting assistance with housing, food, and health insurance. We know that doing these things works to prevent disease, but we are stubbornly unwilling to implement them. That needs to change.
Our primary healthcare system is broken and because of it, Americans are missing out on the chance to benefit from a great deal of science telling us how to prevent many diseases and premature deaths. Fortunately, there is now widespread agreement that funds must be directed toward a bold revamping of how we deliver primary care.