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Case Study Essay: Option A
Chosen Country: United States of America
Primary care plays a central role in a healthcare delivery system of the United States. Compared to primary care services that include prevention, diagnostic and therapeutic services, secondary care services (hospitalization, consultation & routine surgery) and tertiary care services (trauma and burn treatment) are more complex and specialized, and the types of care are further distinguished according to duration, frequency, and level of intensity. Primary care in United States are delivered by three specialties family medicine, general medicine and general pediatric. In 2008, United States had among 954,224 total doctors of medicine, 784,199 were actively practicing and 305,264 were practicing in primary care specialties (32% of the total and 39% of actively practicing physicians). The proportion of specialists was over 60% of all patient care physicians. However, United States still lags behind other developed countries in both population health and health system performance. The history of primary care can be traced back a century in the United States which has expanded through the knowledge of physiology that led to biomedical model of disease. Reforms in medical education in 1910 setup a stage for creating a specialization within teaching hospitals. During 1990, the United States care organizations took UK NHS approach for using primary care physicians as gatekeepers but due to demographic differences, United States patients were not accustomed to obtaining a permission of a primary care physician before seeing a specialist. The reason for using physician as gatekeepers was to improve the quality of care and decrease the cost of services. There was increase in the demand for US primary physician in 1990, however, increase in paperwork outweighed the benefits. As per recent publications, the most of people in United States are skeptical about primary
healthcare providers claim to deliver comprehensive primary care including their ability to use technology for better treatment and care. Primary care doctors (generalists) usually lack respect in academic circles due to their operational challenges, such as administrative burdens, inflexible appointment schedules and brief visits hinder their performance which leads to lack of satisfaction from both the patient and the provider. To share some work load from primary care physicians, hospitalists and disease management programs were rolled in United States healthcare system to create a high-volume niche out of area of practice and replace broadly based activities of primary care physicians. Hospitalists movement is based on the idea that primary care physicians should hand over the care of their patients when admitted to hospital to team of doctors based in hospital rather than try to attend them themselves which is financial lucrative because most of the primary care doctors work in hospitals are paid well. The rapid advance of medical technology contributed to the demand for specialty services than primary care centers.
In general, healthcare coverage in United States is provided through combination of private health insurance and public health insurance but it is worth noticing that health insurance providers provide higher insurance reimbursement for specialists relative to primary care physicians which contributes to the current imbalance. Many insurance companies pay more for hospital-based complex diagnostic and invasive procedures but not for routine preventive visits and consultations which makes difficult for primary care centers to attract patients. Policy makers and general public also has very little knowledge of the effectiveness of primary care and its impact on population health which often leads to unnecessary political commitment and disengagement of related sectors. Challenges faced in primary care that has hindered its development are dissatisfaction, long hours, high stress, poor reimbursement, and erosion of
scope of practice. Primary care doctors in United States are paid lower salaries than hospital specialists. Most of the recent graduate doctors in United States who take education loan prefer to go for specialists (generalist physician and radiologist) careers than work in a primary care. Primary care doctors are paid through fees for service model which forces doctors to attract and increase patient volume rather than continuity, comprehensiveness, or integration of care. Low financial margins for primary care doctors make it difficult for them to deliver high quality care. To provide, Effective team-based care in primary care, doctors in United States requires electronic health record which is expensive to implement without any government support.
To strengthen the primary care system and make it successful in United States, political heads and policy makers have implemented various measures such as changes in Medicare fee schedule which had previous favored specialists in reimbursement rates, encouraged support for Title VII health professions training programs, and the most talked about Affordable Care Act (ACA), looking into expanding the role that Nurse practitioners, and Physician assistants to reduce the burden on primary care physicians. The success of primary care in United States are stated in various research studies which concluded that presence of greater primary care availability in a community is correlated with both better health outcomes and a decrease in utilization of more expensive types of health services, such as hospitalizations and emergency department visits.
Key elements of family medicine and primary care in primary care system are defined by WHO in 1978 through Alma-Ata Declaration which acts as baseline in assessing the breadth of primary care services and monitoring of primary care quality. These six elements are ease of access, the clinical quality of the care, interpersonal aspects of care, continuity, and coordination. Level of
access to primary care is dependent on various subfactors which can hinder or facilitate the quality of care. Sub-factors that can hinder the ease of access can be the availability of after-hours care, the length of office wait time, travel time to an appointment, lack of a specific Primary care physician at the site of primary care, and lower perceived flexibility in selecting a primary care physician. While sub-factors that can facilitate ease of access are improved access to primary care may also improve the continuity of care for patients with depression. It is worth to mention that in United States depending the insurance type patients may experience different level of quality of primary care. The continuity key factor in primary care quality can be affected by appointment wait time length, the insurance status of patient, and after-hours care availability.
Overall, the United States policy makers are trying to strengthen the primary care system through various reforms, however, due to shortage of primary care physicians, low wages, lack of acceptance by American people it has been very challenging to encourage pre-existing medical students to choose careers as primary care physicians over specialists.
Most of the articles and papers used to collect data for this case study has been published in world class journals and written by research fellows from John Hopkins School of Public Health & other well-known institutions. These articles are frequently cited by various authors doing research in the similar field which validates its authenticity. However, as stated in every research paper, most of the reference work showcase the authors’ own work and there is always a scope of expanding the body of knowledge and testing the waters for future research.
- Shi. L, “The Impact of Primary Care: A Focused Review,”Scientifica, Vol. 2012, Article ID 432892 pp. 22
- Sandy. G.L, Bodenheimer. T, Pawlson. G.L, Starfield.B, (2009)” The Political Economy of U.S Primary Care,’ Delivering on Global Health, vol 28, no.4
- Philips. L.R, ”Primary Care in the United States: problems and possibilities”, BMJ 2005. Vol 332(7529), pp.1400-1402.
- Bindman. B. A, Majeed. A, “ Organisation of primary care in the United States”, BMJ 2003. Vol 326(7390), pp. 631-634
- Grumbach K, Selby JV, Damberg C, Quesenberry C, Jr, Truman A, et al. Resolving the gatekeeper conundrum: what patients value in primary care and referrals to specialists. JAMA. 1999;282:261–266
- Bates. W. D, “ Primary Care and the US Health Care System: What Need to Change?”, J Gen Intern Med 2010. Vol 25(10) pp.998-999
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