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Primary Care: Divergent Paths In U.S. And Abroad



November 14th, 2008

The contrast could hardly have been more sharp. In a week when The New England Journal of Medicine published a series of perspectives exhorting the United States to reinvent primary care before it collapses, speakers at the annual international symposium of The Commonwealth Fund emphasized how primary care physicians formed the critical core of health-care systems in the Netherlands and the United Kingdom, while patients in France, Germany and Switzerland are encouraged through financial incentives to register with a generalist doctor. All of the countries represented at the symposium provide universal access, or nearly so, to their citizens.

Health ministers or their lieutenants from nine countries (Australia, Canada, England, France, Germany, New Zealand, Switzerland, The Netherlands and the United States) gathered at a roundtable discussion moderated by Susan Dentzer, editor-in-chief of Health Affairs, to discuss the issues facing their health care systems. The status of primary care services in these countries was one of the major topics of conversation.

The health-care systems of all of these countries face many similar challenges — among them the need to coordinate care more effectively, to accelerate implementation of health information technology and to recognize the coming era of chronic disease — but most of them, with the exception of the United States, address them based on a strong belief that ready access to primary care is step one in any rational system. More than perhaps any other system, the United Kingdom’s National Health Service has elevated the importance of ready access to primary care services over the last decade by increasing its fees to generalist physicians by billions of pounds. Primary care physicians in England now have annual incomes that average, $220,000, which is more than many specialists earn.

Alan Johnson, secretary of state for health in the British government, emphasized the key role of primary care doctors in his remarks to the Fund’s 2008 International Symposium and also underscored the enlarged role that nurses are playing in tandem with doctors in managing the care of patients that have one or more chronic conditions. This finding was one of many that derived from a survey of patients in eight countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom and the United States) who lived with one or more chronic condition.

The vast majority of patients who participated in the survey reported a regular source of care. By contrast, U.S. patients were significantly less likely than others to have a personal physician or long-term relationship with a doctor. The extent to which chronically ill adults used hospital emergency rooms tended to track country patterns in ease of access to primary or after-hours care. Emergency room use was significantly higher in Australia, Canada and the U.S., than the other five countries—including addressing concerns that many patients thought could have been treated more efficiently and less costly by their regular physician—if that practitioner had been available.

However, even in the United Kingdom, primary care doctors do not always deliver nirvana to patients. Lord Ara Darzi, parliamentary under secretary of health at England’s Department of Health, told the Commonwealth Fund conferees that there were “serious failings” in the coordination of care between primary care doctors and specialists. Increasingly, primary care physicians in England are working in multidisciplinary teams, with nurses taking on greater responsibility for the routine management of people living with chronic disease. Lord Darzi recounted that his patients (he is chair of surgery at the Imperial College of London) tell him how valuable the care delivered by his nurse is to their well-being.

In July 2007, Prime Minister Gordon Brown announced that Darzi would lead a review of the National Health Service and develop recommendations on how the service should address future challenges. Among the priorities that Darzi recommended and highlighted at the Commonwealth symposium was a call for “personalized budgets” in which individuals living with chronic conditions would be granted a sum of money to purchase their own care within prescribed limits set by the health service. The National Health Service is in the process of developing 20 pilot projects in different regions of the country that would experiment with this concept. The initiative is building on a program already in place that provides individuals in need of an array of social services (feeding, bathing, dressing and shopping for groceries) financial support to purchase these services from approved vendors.

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1 Response to “Primary Care: Divergent Paths In U.S. And Abroad”

  1. acavale Says:

    Intersting observations. One line strikes me as interesting … “U.S. patients were significantly less likely than others to have a personal physician or long-term relationship with a doctor”. In my opnion, a solution to this problem could address multiple issues associated with the US healthcare system at this time – access to care, cost of care, coordination of care, and improvement in the medicolegal situation.

    There are at least three probable causes for this phenomenon (effective dismantling of the patient-physician relationship):
    1) Unscruplous trial lawyers who continue to drive a wedge in this most sacred relationship
    2) Business-minded insurers who create “in-network” and “out-of-network” groups of physicians, resulting in elimination of many community physicians by default. This results in patients being shifted from one practice to another based only on who is “in-network”.
    3) Untimely disappearance of many (mostly Primary care) physicians due to unbearable regulations/cost of doing business/lack of successful business model for small practices/small practice takeovers by local hospitals, etc.

    Unfortunately, almost all current efforts (both governmental and private) have gone towards helping promote large goup model practices, which may work well for process-efficiency but does harm to promoting a long-term patient-physician relationship. A better way would be to simplify the proceses and create a viable business model for small practices to flourish in communities, thereby ensuring their longevity and subsequently helping develop lasting, trusting patient-physician relationships.

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