Investment In Primary Care Research Articles

Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians.

Visual Abstract.Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians Visual Abstract. Envisioning a Better U.S. Health Care System for All: A...

COVID-19 and the Case for Medical Management and Primary Care.

Hospitals and health systems suffer an over-reliance on elective surgeries to remain profitable. As a result, systems report record losses, while demand for emergency room, hospital, and intensive care beds have surged. Studies have admitted that many surgeries are unnecessary, and physician leaders admit that profit plays a role in driving such needless cost and risk. Most diseases are better managed with medications and lifestyle changes. But it pays more to replace a knee than to prevent that replacement. We must bring surgical and medical value closer in-line. Communities of color are suffering disproportionately from coronavirus. The social determinants of health that lead to higher concentrations of hypertension and diabetes can be mitigated by investment in primary care. Such investment has been proven to decrease cost and increase quality of life. However, the United States spends 50% less on primary care, than other developed countries. While showing promise, telehealth is not a panacea. It relies on continued reimbursement parity, and there remains a digital divide. Any meaningful fix will draw the ire from those who profit from such a profligate system. If we want to improve quality, access and equity, while avoiding unnecessary hospitalizations, risky surgeries, and runaway costs, we must invest in primary care.

Measuring and Increasing Investment in Primary Care: Delaware Marches On.

Measuring and Increasing Investment in Primary Care: Delaware Marches On.

Identifying priorities for primary care investment in Ireland through a population-based analysis of avoidable hospital admissions for ambulatory care sensitive conditions (ACSC)

BackgroundIn 2016, the Irish acute hospital system operated well above internationally recommended occupancy targets. Investment in primary care can prevent hospital admissions of ambulatory care sensitive conditions (ACSCs).ObjectiveTo measure the...

Tinkering at the margins: evaluating the pace and direction of primary care reform in Ontario, Canada

BackgroundPrimary care reform has been on the political agenda in Canada and many industrialized countries for several decades; it is widely seen as the foundation for broader health system transformation. Federal investments in primary care, including major cash transfers to provinces and territories as part of a 10-year health care funding agreement in 2004, triggered waves of primary care reform across Canada. Nevertheless, Commonwealth Fund surveys show, Canada continues to lag behind other industrialized nations with respect to timely access to care, electronic medical record use and audit and feedback for quality improvement in primary care. This paper evaluates the pace and direction of primary care reform as well as the extent of resulting change in the organization and delivery of primary care in Ontario, Canada’s most populous province.MethodsQualitative and quantitative methods were used for this study. A literature review was conducted to analyze the core dimensions of primary care reform, the history of reform in Ontario, and the extent to which different dimensions are integrated into Ontario’s models. Quantitative data on the number of family physicians/general practitioners and patients enrolled in these models was examined over a 10-year period to determine the degree of change that has taken place in the organization and delivery of primary care in Ontario.ResultsThere are 11 core reform dimensions that individually and collectively shift from conventional primary care toward the more expansive vision of primary health care. Assessment of Ontario’s models against these core dimensions demonstrate that there has been little substantive change in the organization and delivery of primary care over 10 years in Ontario.ConclusionsPrimary care reform is a multi-dimensional construct with different reform models bundling core dimensions in different ways. This understanding is important to move beyond the rhetoric of “reform” and to critically assess the pace and direction of change in primary care in Ontario and in other jurisdictions. The conceptual framework developed in this paper can assist decision-makers, academics and health care providers in all jurisdictions in evaluating the pace of change in the primary care sector, as well as other sectors.

Veterans Health Administration Investments In Primary Care And Mental Health Integration Improved Care Access.

Aiming to increase care access, the national Primary Care-Mental Health Integration (PC-MHI) initiative of the Veterans Health Administration (VHA) embedded specialists, care managers, or both in primary care clinics to collaboratively care for veterans with psychiatric illness. The initiative's effects on health care use and cost patterns were examined among 5.4million primary care patients in 396 VHA clinics in 2013-16. The median rate of patients who saw a PC-MHI provider was 6.3percent. Each percentage-point increase in the proportion of clinic patients seen by these providers was associated with 11percent more mental health and 40percent more primary care visits but also with 9percent higher average total costs per patient per year. At the mean, 2.5 integrated care visits substituted for each specialty-based mental health visit that did not occur. PC-MHI was associated with improved access to outpatient care, albeit at increased total cost to the VHA. Successful implementation of integrated care necessitates significant investment and multidisciplinary partnership within health systems.

The Primary Care Spend Model: a systems approach to measuring investment in primary care

Increased investment in primary care is associated with lower healthcare costs and improved population health. The allocation of scarce resources should be driven by robust models that adequately describe primary...

Skill mix in primary care: the scale and distribution of skill mix in GP practice across England

BackgroundDecades of under investment in primary care and inattention to suboptimal recruitment and retention of GPs and nurses have contributed to a workforce crisis. The General Practice Forward View sets out how the government is planning to achieve a strengthened model of general practice. A key element of this proposal is to expand the workforce by employing an increasingly diverse range of practitioners i.e. ‘skill mix’. The commitment to broadening skill mix in primary care is reiterated in the NHS Long Term Plan (LTP), with the announcement of a 5-year deal to boost investment in primary care. A significant proportion of this investment focuses on increasing the number of ‘new’ roles such as clinical pharmacists, physiotherapists, physician associates, and paramedics.AimThis presentation offers an early analysis of the scale and distribution of current skill mix in general practice across England. This is part of a wider study about how skill mix is affecting outcomes, costs, and experiences of healthcare in England.MethodDescriptive analysis of a longitudinal practice-level workforce data set using the practice-level workforce Minimum Data Set (wMDS).ResultsWe will present early findings about how staffing has changed and average changes within a region or a clinical commissioning group.ConclusionThese data will indicate the extent of progress towards achievement of the LTP vision of skill mix employment. Findings will inform our future analysis of the structures, contexts, and processes of these new ways of working and provide policymakers, commissioners, and practices with evidence about the wider effects of skill mix.

Quality and Experience of Outpatient Care in the United States for Adults With or Without Primary Care

The US health care system is typically organized around hospitals and specialty care. The value of primary care remains unclear and debated. To determine whether an association exists between receipt of primary care and high-value services, low-value services, and patient experience. This is a nationally representative analysis of noninstitutionalized US adults 18 years or older who participated in the Medical Expenditure Panel Survey. Propensity score-weighted quality and experience of care were compared between 49 286 US adults with and 21 133 adults without primary care from 2012 to 2014. Temporal trends were also analyzed from 2002 to 2014. Patient-reported receipt of primary care, determined by the 4 "Cs" of primary care: first-contact care that is comprehensive, continuous, and coordinated. Thirty-nine clinical quality measures and 7 patient experience measures aggregated into 10 clinical quality composites (6 high-value and 4 low-value services), an overall patient experience rating, and 2 experience composites. From 2002 to 2014, the mean annual survey response rate was 58% (range, 49%-65%). Between 2012 and 2014, compared with respondents without primary care (before adjustment), those with primary care were older (50 [95% CI, 50-51] vs 38 [95% CI, 38-39] years old), more often female (55% [95% CI, 54%-55%] vs 42% [95% CI, 41%-43%]), and predominately white individuals (50% [95% CI, 49%-52%] vs 43% [95% CI, 41%-45%]). After propensity score weighting, US adults with or without primary care had the same mean numbers of outpatient (6.7 vs 5.9; difference, 0.8 [95% CI, -0.2 to 1.8]; P = .11), emergency department (0.2 for both; difference, 0.0 [95% CI, -0.1 to 0.0]; P = .17), and inpatient (0.1 for both; difference, 0.0 [95% CI, 0.0-0.0]; P = .92) encounters annually, but those with primary care filled more prescriptions (mean, 14.1 vs 10.7; difference, 3.4 [95% CI, 2.0-4.7]; P < .001) and were more likely to have a routine preventive visit in the past year (mean, 72.2% vs 57.5%; difference, 14.7% [95% CI, 12.3%-17.1%]; P < .001). From 2012 to 2014, Americans with primary care received more high-value care in 4 of 5 composites. For example, 78% of those with primary care received high-value cancer screening compared with 67% without primary care (difference, 10.8% [95% CI, 8.5%-13.0%]; P < .001). Americans with or without primary care received low-value care with similar frequencies on 3 of 4 composites, although Americans with primary care received more low-value antibiotics (59% vs 48%; difference, 11.0% [95% CI, 2.8%-19.3%] P < .001). Respondents with primary care also reported significantly better health care access and experience. For example, physician communication was highly rated for a greater proportion of those with (64%) vs without (54%) primary care (difference, 10.2%; 95% CI, 7.2%-13.1%; P < .001). Differences in quality and experience between Americans with or without primary care were essentially stable between 2002 and 2014. Receipt of primary care was associated with significantly more high-value care, slightly more low-value care, and better health care experience. Policymakers and health system leaders seeking to improve value should consider increasing investments in primary care.

Measuring equity in per capita primary care investment in Ontario: Challenges for data linkage and analysis

IntroductionFifteen years ago almost all primary care physicians (PCPs) were paid fee-for-service. Now, many physicians receive other payments as well, including capitation payments, incentives and bonuses and funding for other health professionals. It is challenging to track these changes in primary care payment and understand how they relate to individual patients.&#x0D; Objectives and ApproachThe objectives of this study were to assess changes in PCP payments from 2002/03 to 2011/12 and examine differences in per capita investment by urban-rural status, recent arrival (proxy for immigrant status) and income quintile. This required a three-step approach: assigning payments to physicians, assigning patients to physicians and then apportioning the payments by patient. Payments were apportioned based on the type of payment and how the data were captured. For example, capitation payments were paid monthly, but without any detail as to which patients they were for, so all capitation payments were summed and apportioned among all rostered patients.&#x0D; ResultsAll PCPs for whom we had payment data and to whom patients could be assigned were included. Three types of physician-patient 'relationships' were identified: the patient was on the physician's formal roster; the patient was 'virtually' rostered to the physician who provided the plurality of their care; or the patient was part of the physician's overall panel, which includes all patients seen during the year, rostered and not. The type of relationship determined which payment were allocated to each patient. When the $3.5B in payments were apportioned and different populations compared, we found inequities in new primary care investment by income, immigrant status and rurality. For example, we found a disproportionate investment in interdisciplinary teams for non-immigrant Ontarians living in more well-off suburban areas.&#x0D; Conclusion/ImplicationsEstimating per capita primary care investment is a challenging but worthwhile undertaking. The results of this study suggest that the Government of Ontario should facilitate increased participation in new primary care models by immigrants and people living in major urban centres.

Internações por condições sensíveis à atenção primária em Novo Hamburgo, Rio Grande do Sul

Objetivos: O presente estudo teve por objetivo analisar a tendência das internações por condições sensíveis à atenção primária (ICSAP) em Novo Hamburgo, comparando-a com o restante do Estado do Rio Grande do Sul, e relacionando-a com os investimentos financeiros em saúde e a cobertura da Estratégia Saúde da Família (ESF) no município, no período de 1998 a 2012. Métodos: Foi realizado um estudo ecológico. Os dados foram coletados do Sistema de Internações Hospitalares do SUS. As causas de ICSAP foram baseadas na lista do Ministério da Saúde. A tendência das ICSAP em Novo Hamburgo e no restante do Estado do Rio Grande do Sul foram analisadas por meio dos seus coeficientes padronizados, pelas médias móveis a cada três anos e pela Regressão Binomial Negativa. Foi realizada análise de correlação entre as variáveis de interesse. Resultados: Apesar do aumento de 329,26% nos investimentos financeiros e da expansão da cobertura por ESF no período, atingindo 20,20% da população, não houve diminuição nas tendências dos coeficientes de ICSAP em Novo Hamburgo. No restante do Rio Grande do Sul houve redução nas ICSAP, contudo, os coeficientes foram maiores do que em Novo Hamburgo no período estudado. Conclusões: Embora no presente estudo não tenha sido encontrada associação entre a diminuição nos coeficientes de ICSAP com o aumento da cobertura pela ESF, incremento do investimento financeiro em saúde, investimento financeiro em APS e o gasto per capita em saúde, há evidências que estes estejam correlacionados. Provavelmente, a cobertura de ESF não foi suficiente para impactar as ICSAP.

Socioeconomic and gestational determinants of birth weight of term infants

Objective: To identify the social and gestational factors associated with birth weight of full-term newborns. Methods: A cross-sectional study was conducted between September 2004 and July 2005. The information was obtained through the Statement of Live Birth and subsequent home visit after the child’s birth. Results: The mean birth weight in the sample was 3,146 (± 375 grams), and the incidence of low birth weight was 7.5%. In the multivariate analysis female children, maternal age less than 19 years, smoking during pregnancy and greater overcrowding in the home were associated with significantly lower mean birth weight. The most significant difference was seen among children whose mothers were smokers, with a mean birth weight less than 258grs compared to nonsmoking mothers (p = 0.001). Jointly, these factors accounted for 16% of the variation in birth weight. Conclusion: Greater investment in primary care is required, in an attempt to reduce the number of adolescent pregnancies and smoking during pregnancy, among other factors relevant to the health of the newborn

Brazil's National Program for Improving Primary Care Access and Quality (PMAQ): Fulfilling the Potential of the World's Largest Payment for Performance System in Primary Care.

Despite some remarkable achievements, there are several challenges facing Brazil's Family Health Strategy (FHS), including expanding access to primary care and improving its quality. These concerns motivated the development of the National Program for Improving Primary Care Access and Quality (PMAQ). Although voluntary, the program now includes nearly 39 000 FHS teams in the country and has led to a near doubling of the federal investment in primary care in its first 2 rounds. In this article, we introduce the PMAQ and advance several recommendations to ensure that it continues to improve primary care access and quality in Brazil.

Association between primary care funding and secondary care usage: a cross-sectional health economic analysis

BackgroundGreater investment in primary care yields better population health outcomes. However, in the past decade general practice (GP) funding has reduced, while general practitioner workload has risen and secondary care funding has increased. To date, the impact of broader aspects of GP funding has not been examined. Using newly released GP financial data, we aimed to explore the association between greater investment in primary care and secondary care usage and costs applied at a national level in England. MethodsWe constructed linear regression models to explore the association between practice funding for essential services and quality and outcomes framework (QOF) achievement, secondary care usage (accident and emergency [A&E] attendance, emergency admission, and outpatient attendance rates per 1000 registered patients), and patient satisfaction, adjusted for practice and demographic variables. We then conducted financial modelling to predict the impact of a hypothetical 10% funding increase on secondary care costs, for which we used standard cost estimates. FindingsWe analysed 7767 practices in England. Mean funding per patient was £79·81 (95% CI 67·01–100·67). Funding was lower in General Medical Services (GMS) practices, which hold national contracts, than in Personal Medical Services practices, which have local contracts (£76·00 [66·52–89·20] vs 84·43 [66·68–107·09]). In GMS practices, greater funding was significantly associated with lower emergency admissions (regression coefficient β=–0·22), lower A&E attendances (−1·04), and higher patient satisfaction (overall satisfaction 0·4). We found no significant association with outpatient attendance or QOF performance. In our financial model, a 10% increase in primary care funding would create a return on investment of 78% in GMS practices overall and up to 110% in GMS practices receiving funding above the national capitation formula. InterpretationGMS practices with higher levels of funding had lower secondary care usage and higher patient satisfaction. The lack of association between funding and QOF achievement might be attributable to the different funding stream and incentives for QOF. Our findings support the case for greater investment in primary care where the value of investment is over and above the national capitation formula. FundingNational Institute for Health Research.

Association between general practice funding and practice achievement: a cross-sectional study

BackgroundIn the past decade, general practice funding has decreased from 11% to 8% of total National Health Service (NHS) spending, while workload has increased by 19%. To date, the impact of broader aspects of practice funding on performance has not been examined. Using newly released primary care financial data, we aimed to explore the association between NHS payments made to general practices in England that are not part of the quality and outcomes framework (QOF) and primary care performance. MethodsPractice funding data were extracted from the National Health Applications and Infrastructure Services. We confined our analysis to practices with the nationally determined contract, General Medical Services (n=4298); data were not available for the locally determined contracts offered to Personal Medical Services practices. We constructed regression models to explore the association between practice funding and QOF outcomes, secondary care usage (outpatient, accident and emergency [A&E], and inpatient rates per 1000 registered patients), and patient satisfaction, adjusted for practice and demographic variables. We then conducted financial modelling to predict the impact of a hypothetical 10% funding increase on secondary care costs, for which we used standard cost estimates. FindingsThe mean funding was £75·71 per patient (95% CI 66·86–87·58). Higher funding was significantly associated with lower emergency admissions (regression coefficient β=0·24), lower A&E attendances (−1·04), and higher patient satisfaction (overall satisfaction 0·002). We found no significant association with outpatient attendance or QOF performance. In our financial model, a 10% increase in primary care funding would cost an additional £7571 per 1000 registered patients, which would be partly offset by a £5323 reduction in emergency admissions and £1031 reduction in A&E attendances. InterpretationGeneral Medical Services practices with higher levels of funding had lower secondary care usage and higher patient satisfaction. The lack of association between funding and QOF achievement might be attributable to the different funding stream and incentives for QOF. Our findings support the case for greater investment in primary care which would largely be offset by reduced secondary care costs and associated with higher levels of patient satisfaction. FundingVSL is funded by a National Institute for Health Research academic clinical fellowship.

Trends in hospitalization for primary care-sensitive conditions and associated factors in Porto Alegre, Rio Grande do Sul, Brazil

An ecological study was conducted to analyze trends in hospitalization for primary care-sensitive conditions linking the results to the investments in health and coverage of the Family Health Strategy in Porto Alegre, between 1998 and 2012. The causes of hospitalization for primary care-sensitive conditions were based on the national list provided by the Ministry of Health. The data were obtained from the Hospital Information System of the Unified Health System (SUS). Standardized rates were created and investments increased by 27%, though investments in primary care increased by 83%. The expansion of coverage by the Family Health Strategy was almost fourfold, though it remained below the recommended values. There was no change in the trend of hospitalization for primary care-sensitive conditions. The analysis did not make it possible to establish if patients who were hospitalized for primary care-sensitive conditions had access to the Family Health Strategy or not, suggesting the need to incorporate data of place of origin in the information system. Studies using the Hospital Information System contribute to its enhancement, fomenting the assessment, management and design of health policies.

Research into practice: accessing primary care.

In global health care,1 and within the UK NHS,2 providing accessible primary care remains a top-level priority for patients, politicians, healthcare planners, and health professionals. At its most basic, ‘access’ is simply the ability of an individual or population to obtain health care. Historical research3 has identified that strong primary care within national healthcare systems is associated with improved health outcomes, lower health system costs, and better patient experience of care compared with settings where primary care is more weakly represented. However, the simple provision of primary care is insufficient to ensure such beneficial outcomes — primary care services need to be made accessible to the population. For example, Kringos and colleagues4 have recently shown that, across Europe, financial investment in health care at national level, and even financial investment in primary care, are in themselves not sufficient mechanisms to drive high-quality access to primary health care. Although a superficially obvious concept, several models of access to health care have been proposed.5–7 Access might usefully be seen as the smoothness of fit between demand for services and the organisation of those services. In the UK, in 1995 a consultation rate of 3.9 per person per year was associated with an annual UK primary care consultation volume of 225 million consultations, by 2009 those figures had risen to 5.5 and 304 million respectively.8,9 This may in part be caused by supplier-induced demand related to more proactive health promotion and chronic disease management, and also by doctors themselves, with inequalities between patients and doctors in knowledge and power resulting in increasing patient demand for services.10 Changes in the provision of care will have an impact on demand and workload. In the UK, the structure and organisation of primary care has changed …

The future shape of primary care

There is no shortage of international policy documents outlining the importance of primary care. But does the reality match up to the rhetoric? This is answered in part in a study by Kringos et al .1 They describe primary care in 31 European countries in terms of investment in primary care, governance, workforce development, access, services delivered, continuity, coordination, comprehensiveness, and GPs’ income. One fundamental, if not surprising observation is that primary care is highly variable. This starts from defining who provides primary care, to whether ‘GP’ means the same thing in different countries, whether GPs work single-handedly or collaborate with others in multidisciplinary teams, whether they have a gatekeeping role, whether they have a registered list and the range of services that are provided, to working conditions and income. Using a wide range of indicators on the different dimensions, Kringos and colleagues developed a measure of ‘strength of primary care’, according to which countries such as the UK, Denmark, and Netherlands rank top, while others such as Austria, Cyprus, Greece, Hungary, and Ireland score poorly on care structures considered key for strong primary care. The study provides a great deal of detail to add to previous surveys documenting wide variation between primary care in different countries.2 In a separate article, the same authors looked …

Spending by primary care practices - does it show what we expect?

Over recent years, a number of policies and financial incentives in primary care have been proposed to tackle issues such as deprivation and health outcomes. This article investigates the association between healthcare spending, deprivation and outcomes. It argues that individual practice data are analysed before blanket application and acceptance that one size fits all in a local area. Financial data were analysed alongside key outcome data, including quality and outcomes framework (QOF) indicators for a large urban primary care trust (PCT) in the UK. The PCT had a large population and number of practices, including single-handed practices and an average list size in excess of 5000. The PCT will remain anonymous. There was no relationship between primary care investment and the practices' deprivation score. There was a strong statistically significant negative correlation between QOF payments and deprivation, (correlation = -0.46, p < 0.001). There were only weak links between primary care investment and health outcomes. There was no relationship between high emergency spending and health outcome. The data presented suggest that one size does not necessarily fit all - in terms of providing the appropriate incentives in primary care, nor do national incentives and policies always have the desired effect.

The strength of primary care in Europe: an international comparative study

A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking. Evaluation of strength of primary care in Europe. International comparative cross-sectional study performed in 2009-2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey. Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts' consultations. Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries. Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.