There’s a significant debate in the U.S. today on what constitutes high value primary care. The runaway train of cost and services, combined with increasing evidence that putting a foundation of primary care in the driver’s seat will lower costs and improve quality, has piqued the interest of those attempting to address low quality and the spiraling costs in American healthcare.

In his new book, “The Voter’s Guide to Healthcare”, Holmes Murphy President Den Bishop lays out many key differences between our current system and one that would serve employers (and their employees) more effectively. One key distinction he articulates in the book is the importance of “Dual Purpose” Primary Care. He accurately points out that in other countries, like Canada where primary care both serves as the first line of defense and acts as the advocate or guide for patients going through the healthcare system, that this reduces redundant, excessive, inappropriate, and non-evidence-based care. This begs the question: would it be possible for us to do the same thing in America?

The first line of defense. 

Primary care services include acute (colds, rashes, sprained ankles, anxiety attacks, etc.), chronic (diabetes, depression, asthma, etc.), and preventive (exams, cancer, other disease screening, etc.).

• Acute — Research suggests that up to 70 percent of the acute problems patients experience on a day-to-day basis are self-limited and will resolve by themselves.
• Chronic — Chronic issues are a bit more involved, and there are specific, very important steps that must be taken (before a person begins to feel bad) if complications are to be prevented.
• Preventive — Finally, preventive exams to screen for pre-disease or early chronic conditions are standard, scheduled, well-defined exams performed at set time intervals based on a patient’s age, gender, and overall risk level.

When a patient has one healthcare provider (or, more likely, a team), symptoms and signs that arise in a person can be interpreted in the context of knowing the patient — their risks, tendencies, likes and dislikes, social determinants, habits, stress level and coping mechanisms, litigiousness, and so forth. Often, not only the patient, but their parents, spouse, children, and maybe even social circle, are known. Thus, the true resources available to the patient can be mobilized. In this context, the decision-making process for patient management choices are more comprehensive, insightful, and appropriate resulting in lower cost and better quality.

Absent of these insights, today’s system consistently defaults to a transactional mindset as much about the doctor’s risk of getting sued as the patient’s health. The question “what will give me a diagnosis and reduce my risk the most?” and “what can I do now (at this visit) to rule out the most serious (and, thus, the most likely to have a bad outcome and possible litigation) conditions?” Therefore, the expensive, unnecessary, “comprehensive” work ups done that cost thousands of dollars could have been avoided in the context of the primary care relationship. For example: If a patient goes straight to a heart specialist with the complaint of chest pain, they are going to make darn sure the heart is not the problem ($600 – $1,200), even if heartburn is their strongest suspicion. The primary care doctor will often treat the heartburn first ($40) and then work up the heart if things don’t get better.

The advocate or guide through the system. 

Approximately 85 percent of issues can be addressed by the primary care provider, but a referral to a specialist is necessary (and important) at times. Not uncommon imaging, procedures, or even surgery result. Selection of the correct specialist, tests, procedures, facilities, and so forth are an important part the process. Having a primary care medical provider who knows the system and the patient simplifies and improves this process, reduces waste (and cost), and is very comforting to the patient.

However, this is very challenging for a primary care provider in the current system. Fragmented medical records, difficult-to-reach busy specialists and hospitalists, dynamic medical situations — not to mention the schedule of the primary care provider — lead to a fragmented and disjointed system. Self-referral to specialists (meaning the primary care provider doesn’t even know care is occurring) also is a significant problem, making supporting high-value care impossible for the primary care provider.

Thus, acting as an advocate or guide to the patient is the most significant challenge in advanced or high-performance primary care. To accomplish this requires considerable expense to the primary care provider. Data management, additional staff, effective communication systems, and insight into a dynamic medical marketplace in the context of the patient’s health benefit options and restrictions is daunting to say the least. Complicating this issue is the lack of compensation for this management, which leads most providers to pass on even attempting. With over 50 percent of physicians now being employed by hospitals and health systems, one might hope that systems would be willing to invest money to make this possible. The challenge with this is that if they do a great job and build these pathways, they would significantly reduce their “upstream” imaging, procedure, facility, and hospital revenue — hardly worth investing significant resources to achieve.

Difficult or not, these two tenants are the crux of advanced, high-value primary care. Providing dual purpose primary care must be achieved for a company to manage the risk and cost of those on their insurance. There are many companies addressing this challenge more successfully. Shifting compensation to primary care from fee for service to payment for value, providing access to data, and giving plan members tools and an advocate to navigate the system are only a few of the initiatives that are being undertaken. The real question is not if, but when, dual purpose care emerges in the marketplace.

Corporations are funding the current system at an average of $12,000 per employee, and they are in a position to demand results. Understanding the importance and options for primary care is a vital part of this process. Every company has a primary care strategy whether they know it or not. Leaving it to chance is too much of a risk for those wanting to win, both financially and as an advocate for their employees.