Trendspotter: Of Primary Care, Budgets, and Healthcare Reform

Are primary-care physicians capable of coordinating care across the spectrum of care settings? That’s the assumption of the growing medical home movement in the U.S. The new coalition government in the U.K. is taking the same idea a step further, by formulating a plan to give general practitioners control of most of the National Health Service’s $160 billion annual budget. Under this plan, which will cut out layers of bureaucracy in the single-payer, government-run system, the British GPs will be responsible for buying services from hospitals, specialists, and other providers.

Not everybody thinks this is a great idea. David Furness, head of strategic development at the Social Market Foundation, a U.K. public policy think tank, has this to say:

“Giving control of NHS funds to GPs is like asking your waiter to manage a restaurant. They might know what you want to eat but they won't necessarily be any good at ordering stock, designing a menu or controlling the chef. Commissioning healthcare is very difficult and needs a specialised organisation to do it. And the evidence suggests that small commissioners find it difficult to take on powerful providers and reform services. GP commissioning risks handing real control of the NHS to vested interests on the provider side as GPs simply won't have the muscle to drive through change.”

The U.K. plan would have the primary-care doctors form regional consortia to manage the budgets. I don’t know whether this would give them sufficient “muscle” to drive hard bargains with other providers, such as hospitals. But primary-care physicians are better situated to divide up funds than other providers are - a fact that will become painfully clear when payment bundling arrives in the U.S. The reason is, because they receive a smaller portion of the health-care pie than specialists or hospitals do, they’d have less self-interest in deciding who gets what.

Moreover, placing primary-care physicians in charge of the budgets that are coming to U.S. healthcare would incentivize them to do as much as possible for patients before referring them out to specialists or sending them to the ER. If we want to restrain cost growth while improving quality, this is precisely what we should do.

As for the “waiters” comparison, this reflects the denigration of primary care that, in the U.S., occurs all too often among specialists and in medical schools. Primary-care physicians care for most of the population and must be able to diagnose a wide variety of conditions, some of them life-threatening. A good primary-care doctor should also know his or her patients well and should guide them as they move across care settings and through various stages of their diseases. Unfortunately, the latter happens too rarely in American medicine, because the current financial incentives discourage it. That’s why the idea of the patient-centered medical home is so important.

Chrysalis, an LPN, an EMT, and a cancer survivor, writes eloquently in a blog post about why primary care is crucial to good healthcare. Primary-care physicians, she says, “are not a means to an end. They are your first line of defense in getting well and staying well…

“Your primary-care physician gets to know you over a period of time. Yes, even with rushed office visits. They get a sense of the person you are. They can get to know your values, your family situation, your job pressures, and maybe even your goals. These may seem like unimportant aspects in relation to your healthcare, but they can all have a profound affect on your health. Knowledge of these things may provide valuable information as they assess what is troubling you.”

Specialists, of course, have a key role to play, too, and primary-care doctors should not be “gatekeepers” who limit access to specialists to control costs. We’ve already gone through that with HMOs, and we shouldn’t repeat that mistake. But a healthcare system run by primary-care physicians-if we could produce enough of them-would be less expensive, higher-quality, and fairer to patients than the system we have today.