How Primary Care Can Solve Today’s Health Care Challenges

Overlooking the fundamental importance of Primary Care (PC), some countries are not only keeping the overall cost of healthcare up at the expense of their citizens, but they are also hindering PC professionals in their role as gatekeepers to their own health system. I explain why PC should be the cornerstone of contemporary health care policies.  

Anne Moyal

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When I arrived to the US in Spring 2019 as a visiting PhD scholar at Columbia University’s School of Public Health, I was immediately struck by the advertising messages all over the streets, convenient stores and public transports that read along the same lines:Keep yourself healthy… keep the doctor away.” Taking the form of public health advices but designed to sell food products, gym subscriptions or health insurance services, these promotional messages gave me the impression that US citizens were considered as being solely responsible for their own health condition. A few months later, a friend came to visit. After a few days in, he realized one of his wisdom teeth was infected. When he chose to wait until his return to France to get it removed instead of being treated in New York, due to prohibitive operation fees, I felt appalled. And a couple of weeks later, when a newly made American friend told me the story of her recent fishing accident, I started to get scared. She had refused to call an ambulance after her boyfriend had called her private health insurance which confirmed that transportation costs to the hospital would not be covered. She decided to order an Uber to reach the hospital, with a fishing harpoon still stuck in her foot!

“The stake here– beyond my personal astonishment– was access to basic health services. I started to ask myself whether or not it was normal to go on suffering from a severe toothache for several days or to go to the emergency room on one’s own using a private ride-hailing app. Who should be held accountable for such health expenses: the individual or society? Are sports, good food and insurance a citizen’s duty? Or is health a right?”

So many questions that I had never personally asked myself in France where I was born and raised–  a country which I proudly considered to be both at the cutting edge of medical technology and at the forefront of care accessibility. Never had I even questioned calling up an ambulance in case of an emergency. Nor do I ever miss any of my annual check-ups which are almost fully covered by the Public Health Insurance, while my 45€ a month complementary private insurance pays for any remaining costs.

Meanwhile in the US, tens of millions of Americans are uninsured. Expensive private healthcare insurances cover most employed citizens and only one-third of the population can apply for public insurance through Medicare and Medicaid. The latter options encompass people over 65, veterans, active military families, people with disabilities, Native Americans and “the poor” who is classified with poverty thresholds varying from state to state and averaging at $12,490 of income at the federal level. Such criteria lead some citizens to decline jobs in order to remain “poor” while others have to resort to crowdfunding platforms such as GoFundMe to pay for unexpected health expenses.

Are we really responsible for our own health?

Paradoxically my experience at Columbia, working in a Department close to the Faculty of Medicine and prestigious hospitals, offered me a very different perspective on health issues in the U.S. It confirmed my understanding that the country was at the forefront of medical research, particularly thanks to massive spending in the health sector (16% of US GDP, a world record) and unprecedented investment by the NIH (National Institute of Health) in fundamental research, amounting to 41.7 billion dollars a year1NIH 2020 budget, https://www.nih.gov/about-nih/what-we-do/budget(around 37.5 billion euros). This is 42 times more than the budget of INSERM (National Institute of Health and Medical Research)2INSERM targets a budget of €927.3M for 2020, https://presse.inserm.fr/service-presse/inserm-en-chiffres/, the NIH’s equivalent in France.

“To this day, the US still remains the reference in medical research. It is home to 45% of Nobel Prize winners in medicine & the birthplace of major health innovations. But such innovations do not rhyme with social progress.

Health level indicators among the overall population display worrying trends. After years of steady progress, life expectancy in the US started to reverse in 2014, reaching an average 78.7 years in 2017, ranking the country’s life expectancy 35th, between Lebanon and Cuba3UNDP, Human Development Report 2019. In comparison, life expectancy was 82.5 years in France and 80.9 years in the EU. The US also ranked 33rd out of the 35 OECD countries in terms of infant mortality4OECD, 2015 Report (i.e. the death of a child before the age of one), just ahead of Turkey and Mexico. Chronic pathologies, one of the causes of premature mortality (i.e. before the age of 65) represent another issue: in 2018, more than 70% of American adults were overweight, including more than 40% qualifying as obese5Centers for Disease Control and Prevention, Report published February 20: “Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018”; https://www.cdc.gov/nchs/data/databriefs/db360-h.pdf, double the average of OECD countries. In short, it is “a superpower with a powerless healthcare system”.6Libération, “Les États-Unis, une super puissance au système de santé impuissant”, February 4th, 2018

Banner hanging at the entrance wall of Columbia University.

Facing this paradox, I remembered the words of prof. Lawrence D. Brown – my mentor at Columbia – who had straightforwardly summed up the situation the very first time we met, before I could even fully grasp of it.

“The US has never recognized a right to health care” he explained. Instead, the country invests in technical innovation and produces an oversupply of specialist physicians while it suffers from a lack of general practitioners (GPs).

The policy paradigm in this field continuously supports a system whereby the costs of preventive7Preventive care is given to you when you’re symptom free and have no reason to believe you might be unhealthy. Preventive care is often given as part of a routine physical or checkup. or routine primary care (see definition below) are not covered, while expensive insurance companies mostly focus on potentially catastrophic costs typically associated with hospital care.

Making the case for Primary Care

Although they are not exclusive to the US, such policy choices seem surprising when looking at the literature on health systems. Since the 1970s, researchers in different disciplines have shown that access to Primary Care (PC) correlates not only with better health outcomes for patients, but it also reduces costs for society as a whole (Macinko, Starfield, et Shi 2003; Starfield 1994; Starfield et Shi 2002).

So… what is Primary Care? Could it help alleviate the health crisis currently affecting the US? Should we increase our focus on PC in Europe at a time when ‘traditional’ state support to healthcare systems is under growing pressure? 

The WHO (World Health Organization) defined PC for the first time at the 1978 International Conference on Primary Health Care in Alma Ata.8https://www.who.int/publications/almaata_declaration_en.pdf Since then, 4 core principles emerged from this initial definition:

1. PC is the first level of contact patients have with healthcare systems, implying that PC providers (including GPs, nurses, physiotherapists, midwives, etc., and even social workers in some countries) become the gatekeepers of the healthcare system, thereby referring patients to the right specialists when they deem it necessary.

2. PC addresses main health problems in the long term and on a recurring basis. However, for specific and complex health conditions PC providers usually refer patients to more specialised professionals which ensures coordination among care providers.

3. PC is accessible to individuals at an affordable rate, covering a broad range of healthcare needs with no condition on age, gender, income, etc.

4. PC provides a large array of care, including promotive, preventive, curative and rehabilitative services (see Box 1 below.)

Box 1. The wide scope of Primary Care

The 1978 WHO declaration on PC insists that PC provide a wider scope of care in an effort to promote better health, prevent illnesses at early stages, provide precise and accurate diagnoses, and rehabilitative services. This concept of healthcare is based on 2 observations made in regard to patients:

1. Lifestyle (smoking, diet, exercise, substance abuse…) and environmental determinants (air, water, workplaces, …) have an impact on the apparition and development of diseases (Lalonde 2002). 

2. Social determinants (upbringing, housing, income, social environment, socioeconomic status, racism, discrimination…) are considered more and more to play a big role in the development of illness and disease. (Marmot 2005, 2015).

Not only does the above definitions aim for a level of “social justice” (Bourgueil, Jusot, et Leleu 2012), it also supports new principles around the organisation and financing of healthcare systems.

Evidence on the virtues of Primary Care

At the beginning of the 2000s, researchers of the Primary Care Policy Center of the John Hopkins University (Macinko, Starfield, et Shi 2003; Starfield et Shi 2002) compared PC implementation in 18 OECD countries over three decades (1970s to 1990s) and gave each of them a score, taking into account different PC characteristics: mode of PC financing, scope of care, proportion of physicians involved in PC versus specialists, level of costs for patients, 24h access arrangements, etc. Although all of these countries have improved their ‘PC score’ since the 1970s, some have been more PC-oriented than others.

  • Countries scoring above the mean (from highest to lowest score) include Denmark, the UK, the Netherlands, Italy, Australia, Norway, Spain, Finland, Canada and Sweden.
  • Countries scoring below the mean include Japan, Portugal, Germany, Belgium, Greece, Switzerland, France and USA.

Using PC scores, John Hopkins Hospital researchers have shown that developing PC is an effective policy tool to (1) improve health outcomes for the population and (2) keep healthcare costs down for society:

1. In countries with higher PC scores, premature mortality due to chronic diseases (such as asthma, bronchitis, cardiovascular disease and heart disease) was lower than in countries with lower levels of PC development.

2. The cost of PC development is low for society as a whole, as total healthcare expenditures per capita was negatively correlated with PC scores (Fig. 1).

Figure 1: Primary care score vs. health care expenditure, 1997 (Source: Starfield et Shi 2002) Each country was assigned a score between 0 and 2 (0 indicating absent or poor PC development and 2 indicating high level of PC development).

The table shows that the US combines a high level of spending per capita with limited PC development. Surprisingly, France, Belgium and Germany also showcase very low PC scores. This can be explained by the very late development of PC9Since the 2000s in these countries due to lack of regulation faciliating access to care, and the autonomy granted to private PC providers10For example, in the UK, GPs and primary care nurses are employed by care facilities called Primary Care Trusts. Whereas in countries such as France, Belgium & Germany, primary care providers are private, meaning they are directly paid by patients and have the freedom to organise their practice as they see fit (schedules, coordination, process, etc.) and without being subject to any reporting requirements to any public authority.. However, the recent health indicators in these 3 countries are far less worrying than those of the US. We believe there are two explanations for this: First, the healthcare systems in France, Belgium and Germany are characterized by high levels of public spending and reliance on social-security systems. As a result, the remaining costs paid by patients are moderate. Secondly, public hospitals are highly developed and subsidized, and often act as a PC option, constituting the first contact point for patients seeking care. Healthcare accessibility is therefore guaranteed in those countries regardless of the patient’s income, but at a systemic cost that may not be sustainable in the long term.

These studies lead us to the conclusion that developing PC could lead us to a better solution in health care. It would make basic care more accessible to everyone and helps reduce (health) inequalities, while keeping such inequalities low in the long-term. Also, by treating people early on through routine visits (hence avoiding costly specialized care), it creates a more sustainable system by keeping the overall cost of health care down.

Not often do we see such a clearly identified policy lever that can effectively help improve the situation for all. We should encourage policymakers to shift the focus to PC now in order to realize its full potential (see Box 2).

Box 2. Some figures about primary care today demonstrate room for improvement11OECD, “Realizing the Full Potential of Primary Health Care”, Policy Brief, Released 16 May 2019 

  • Only 14% of total health spending is devoted to PC across OECD countries.
  • The share of GPs among all physicians has dropped from 32% in 2000 to 29% in 2016 across OECD countries.
  • 26% of patients suffering from chronic conditions did not receive preventive tests in the past 12 months across EU countries.
  • 6.7% of hospital bed days in 2016 (costing more than $835 million) correspond to patient suffering from chronic conditions which could have been treated in PC.

 

This article was edited by Guillaume Le Tarnec who is an independent editor and advisor specialising in institutional communication and development strategy. He holds a bachelor in Politics with Economics from the University of Bath and a Master in Communications from Sciences Po Paris.

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Anne Moyal

Anne Moyal is a PhD fellow in sociology at Sciences Po Paris, affiliated to the Center for the Sociology of Organisations (CSO) and the Laboratory for Interdisciplinary Evaluation of Public Policies (LIEPP). She currently works under the supervision of Henri Bergeron, CNRS/Sciences Po research fellow and Scientific coordinator of the Sciences Po Chair in Health Studies. Before joining Sciences Po doctorate program, Anne worked as a healthcare consultant for three years, taking part in different projects aiming to re-organise primary care provision in France. This experience pushed her to ask several theoretical questions which she decided to empirically test with her academic work today. Anne also took part in a visiting program at the Mailman School of Public Health at Columbia University (New York) in Spring 2019, under the mentorship of professor Lawrence D. Brown.
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