A Healthy Balance

While, in theory, I understand how a robust primary care system would be more cost effective to not only the individual, but the society as well, there tend to be faults to the system, at least in the United States, that need to be addressed before we can rely on primary care entirely to help lower health care costs. Overall, if you have a system where individuals are less likely to pay exorbitant out of pocket expenses, that individual is more likely to seek preventative medical care, thereby increasing his/her own health status. This idea is appealing, however, it’s not this simple.
Primary care aims to improve the functioning of the overall health system by promoting prevention, better referral and coordination of health care, and finally, continuity of care. Starfield, Macinko, and Shi suggest in this week’s reading that the United States enjoyed slight improvement of our primary care system from the years 1970 to 1998, mainly due to participation in HMO plans. This benefit may be obsolete considering that pariticpation in HMO plans has decreased since the 1990’s (91.6 million in 1996 as compared to 66.8 million in 2007, http://www.statehealthfacts.kff.org/profileind.jsp?rgn=1&ind=348&cat=7), mainly due to decreased access to care and physician disapproval of HMOs. In April 2007, legislation aimed to require some of the Illinois medicaid patients to enroll in HMOs had physicians fuming (http://www.chicagotribune.com/business/chi-thu_notebook_0823aug23,0,495722.story). This and other examples show that physicians are still not ready to relinquish the reins to health maintenance organizations just yet.
Speaking from personal experience, I found the HMO plan to be extremely inefficient. While I understand that the gatekeeping method may be necessary for people who tend to crowd specialists’ offices for common ailments, if you happen to injure your knee, for example, and it takes 3 months to figure out what is wrong, well, that simply seems unreasonable. It seems that while the idea of gatekeeping and better coordination of care is appealing, I don’t think that we’ve quite perfected this in the US. I didn’t feel that my physicians were talking to each other at all throughout my experience, hence the coordination of care seemed to be lacking. With regards to referrals, I had to wait, what seemed like an unnecessary amount of time to see my PCP, just to hear that I had to see a specialist. RIGHT. I think that I knew that before.
Furthermore, we simply don't have the resources to promote primary care as the main source of health care in the states. This is evident by the simple fact that only 31% of US-trained physicians go into primary care, as compared to 69% of subspecialists (Starfield B, Fryer G. The Primary Care Physician Workforce: Ethical and Policy Implications). It is also suggested that foreign physicians help maintain our pool of PCPs. This would be fine if it didn't mean that we were depleting those countries of their own resources. Thinking about this, in order to maintain a healthy primary care system, shouldn't the United States encourage their own MDs to go into general medicine, perhaps through incentives, salary increases, etc.?
Taking all of this into consideration, until we are able to increase the quality of primary, managed care, and provide adequate resources for it, there needs to be a healthy balance of primary, specialty, and hospital care.