Primary care and the health care cost curve

Guys, I need to submit a blog post to policy2.org to kick start a conversation amongst policy makers and academics on the role of primary care in health reform. Specific question I was asked to answer was "how does primary care bend the cost curve". This is my response - can you give me some feedback in the next 18hrs? Argument flow is weak at points. Doesn't need to win any awards - just start conversation. Need to submit by end of work day tomorrow:

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Expanding primary care will not bend the cost curve.

All primary care doctors do is postpone the time of eventual death. The patient lives longer and ultimately develops new and more costly diseases that are the consequences of aging.

Ever heard these arguments? I have and it’s fascinating. Intuitively, this makes sense to me. In the cold calculus of economics, good primary care will prevent disease and extend life. As they say, taxes and death are both inevitable. And death costs money, and I have to believe death when you are older is more costly than death when you are slightly younger.

I’m making two huge sweeping assumptions here. First - Primary care saves lives. Second – Death when you are older costs more money to the system. I did a quick literature search to challenge these assumptions.

So let’s question the first assumption – does primary care save lives?

Mackinko et al.did an interesting little interesting literature review in the International Journal of Health Services in 2007. They pooled together a series of studies, re-cut the data in order to assess primary care effect size and the predicted effect on health outcomes of a one-unit increase in primary care physicians per 10,000 population. What they found was interesting - Primary care physician supply was associated with improved health outcomes, including all-cause, cancer, heart disease, stroke, and infant mortality; low birth weight; life expectancy; and self-rated health. Pooled results for all-cause mortality suggested that an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3 percent, or 49 per 100,000 per year. Not bad.

I am assuming this is not surprising. Primary care physicians include family medicine doctors, internists, pediatricians, and in some instances, obstetrician–gynecologists. Currently, primary care accounts for about one third of the physician workforce in America. For many, primary care physicians are the first contact for a person with an undiagnosed health concern, they provide patients with the opportunities to prevent disease and they offer continuity and coordination of care for many complex conditions. Given their pivotal role in delivering care, it follows reasonably that they will save lives.

Now the second question – does primary care save money?

This is the tricky one. But one of my favorite studies on this question is from Lubitz et al. from his New England Journal article entitled “Health, Life Expectancy, and Health Care Spending among the Elderly” in 2003. They found that elderly persons in better health had a longer life expectancy than those in poorer health but had similar cumulative health care expenditures until death. A person with no functional limitation at 70 years of age had a life expectancy of 14.3 years and expected cumulative health care expenditures of about $136,000 (in 1998 dollars); a person with a limitation in at least one activity of daily living had a life expectancy of 11.6 years and expected cumulative expenditures of about $145,000.

Goetzel had an interesting framing of this question in his 2009 Health Affairs article: “Providing certain preventive services, mostly in clinical settings, does not save money. But, then again, neither do most medical treatments. The issue relevant to this debate is how much value is achieved for any given preventive or treatment service. Instead of debating whether prevention or treatment saves money, we should determine the most cost-effective ways to achieve improved population health, and where to focus scarce resources to get the "biggest bang for the buck."

Note that I did not ask “does prevention save money?” If asked, I’m not sure I could defend the assertion that “prevention saves money.” For example, screening costs can exceed the cost of treatment if only a small portion of a population would get sick without any preventative services. As a society, it might be cheaper to simply treat, and not always prevent.

The question I asked, however, was “does primary care save money?” The role of the primary care physician is not just prevention. Not to be heavy-handed, but I do believe they are the guardians of health – they help the patient navigate the complex decisions of life and health – of prevention and treatment. I believe this is how the primary care physician helps control costs – by helping patients make rational decisions about their care, and providing the longest and healthiest life as possible.

These are just some quick thought starters. I now hand the conversation over to you. I encourage you to use Policy2.org to more fully engage each other, challenge and explore the data, and construct the story that helps us tell the American people that primary care physicians play a vital role in creating a healthier country with greater economic opportunity for all.