What is the future purpose of primary care? From gatekeeper to the coordinator of self-care and specialized care?

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Pre-conference roundtable discussion “What is the future purpose of primary care? From gatekeeper to the coordinator of self-care and specialized care?”
By Thomas Rundall

Health professionals from the Netherlands, Germany, Sweden, Turkey, and the United States participated in the roundtable discussion of the future role of primary care. Major points discussed during the roundtable discussion include the following:

Primary care was defined as that care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis, development of a treatment plan, and treatment of acute and chronic illnesses. To effectively provide primary care, the provider’s role must extend well beyond that of a gatekeeper, approving specialty care and hospital services for ill or injured patients. The primary care provider must be a “connector,” connecting patients with providers and service organizations that are required to implement the patient’s care plan, sharing information, and coordinating the care provided across the continuum of care.

The development and use of primary care differs greatly across countries. In many countries in the Middle East, such as Turkey, primary care as defined above does not exist. In other countries, such as the Netherlands, primary care providers still function primarily as gatekeepers, with little responsibility for care planning, coordinating, and monitoring activities. In some countries with established primary care services, many patients are “cutting out” primary care and self-referring to specialists. Finally, in some countries, including the United States, health care entrepreneurs are disaggregating activities provided by primary care clinicians and attempting to provide some of those services in a different way, such as developing information technology applications that can be used by clinicians or patients to assist or replace the connecting and information-sharing functions of primary care providers.

Efforts in nearly all countries to reduce the rate of increase in health care expenditures are having both intended and unintended consequences for primary care. Three approaches to expenditure control were discussed. In some countries, including the United States, all three approaches (and more) are being used.

  • Shifting financial risk to providers with fixed annual provider budgets; this approach discourages unnecessary testing and care services by primary care providers, but often results in primary care access problems and the unintended consequence of the primary care provider inappropriately referring patients to specialists in order to avoid exceeding their budget limit.
  • Shifting financial risk to consumers/patients via high deductibles and coinsurance provisions in health plans; this approach reduces demand for primary care services by increasing the out-of-pocket costs for consumers/patients. Consumer/patient cost sharing may reduce unnecessary use of primary care, but it also may reduce appropriate use of needed care.
  • Improving community health through health promotion/disease prevention, early detection of health problems, and aggressive use of primary and secondary (as needed) care to reduce the overall demand of medical care services. In such efforts, primary care is viewed as an essential component, working closely in a coordinated way with various “upstream” services to promote health and prevent illness and injury across the life cycle. While this “public health” model has enormous potential to improve community health and reduce demand for primary care and other medical services, the effects of health promotion and disease prevention programs are often found to be weaker than hoped and to take effect over a long period of time.

The role played by primary care in any health system is largely driven by the cultural beliefs in the medical and general communities about the proper way to organize, finance, and deliver medical services. To the extent that the increasing cost of medical care over time is perceived to be a significant problem, the role that primary care will be asked to play in controlling those costs will largely conform with those cultural beliefs. In some countries, achieving acceptance of primary care as defined above and implementation of primary care services that complement and coordinate specialty care services in ways that improve patient services and outcomes may require dedicated efforts to improve understanding of primary care and acceptance of the special role primary care plays in improving the health of individuals and populations.

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