As a health care practitioner, I often hear things like, “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 hear these arguments? It’s fascinating - intuitively, this makes sense to me. In the cold calculus of health care economics, good primary care may prevent disease and extend life, but as they say – taxes and death are both inevitable. And death costs money. I have to believe that postponing a sudden death at a younger age with a prolonged illness and likely ICU stay at an older age is costly.
I’m making two huge sweeping assumptions here. First - Primary care saves lives. Second – when you die older, you cost more to the system. I did a quick literature search to see that I could find to answer these questions. 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. In other words, 49 more people would live each year with the addition of just one more doctor. 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. In other words, a healthy spry grandmother who still does all her own cooking may live longer, but she will cost the system about the same amount of money as her sister who requires round-the-clock nursing assistance.
When a colleague of mine worked briefly in Canada, he looked at cost data that showed that annual health care costs for patients who lived rose over the course of life. This is not surprising. Costs for patients who died (of natural causes) were pretty constant - dying of breast cancer costs the same at 55 as 85. So if you simply prolong life, then costs will go up. Of course, if you enable people to work longer, then GDP goes up, so costs as a percent of GDP are mitigated. So retirement age becomes a factor. This is Canadian data, but I doubt the US is that different.
But the question is can we decrease those annual costs of living and dying, and is primary care critical to this? The answer is yes. Changes in the structure of primary care practices as well as the reimbursement can reduce costs. An example is care coordination - several pilots have shown that if you improve the coordination of care of high-risk patients, they generate fewer costs. Massachusetts General Hospital’s CMS Demonstration project is one successful example. Tom Bodenheimer reviews other examples in a recent New England Journal of Medicine Article.
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 and coordinate 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.
About The Author:
Sree Chaguturu is currently an internal medicine physician at Massachusetts General Hospital / Harvard Medical School and a health care consultant at McKinsey and Company. He provided primary care for a number of years in a community health center in Charlestown, Boston.
