Primary Care is Still the Answer

Though the has been praised as the ultimate strategy in keeping patients out of emergency departments and hospitals, so far the actual results have been mixed. A new study out of California, however, provides more positive evidence for the benefits of a continuous, longitudinal relationship with a primary care physician.

The Health Care Coverage Initiative in California created a provider network and defined benefits for a previously uninsured population that was ineligible for Medicaid, Medicare, or other public programs. Patients were assigned to a medical home consisting of a primary care provider who maintained the patient’s medical records, coordinated his care and was his primary source of medical care. In the first two years of the program, patients were not required to be compliant with their assigned primary care provider, and only about 40% were.

This study found that in patients who were always adherent with their primary care provider, the percentage who have two or more annual ED visits decreased from 4.11% to 3.13%, as did those who had two or more annual hospitalizations (1.37% to 1.17%). These highly adherent patients also had a higher chance of having no ED visits and a higher chance of having no hospitalizations.

While these data are statistically significant, the size of the effect was small and I wonder whether the cost of implementation of this initiative would be recouped through a decrease in uncompensated ED visits and hospitalizations.

Additionally the sample population, adults under 65, were relatively young.  This group did not have more advanced or serious diseases such as COPD, congestive heart failure, and coronary artery disease which often result is costly admissions and readmissions. It would be interesting to see if primary care adherence through this program was associated with prevented progression to these and other more advanced diagnoses.

The idea of limiting a patient’s provider network is interesting, and has been an oft worried-about consequence of the Affordable Care Act. It is heartening to see that such limitation can have a positive impact, however small, on patient-centered outcomes.

commentary by Vidya Eswaran

Abstract

The expansion of health insurance to millions of Americans through the Affordable Care Act has given rise to concerns about increased use of emergency department (ED) and hospital services by previously uninsured populations. Prior research has demonstrated that continuity with a regular source of primary care is associated with lower use of these services and with greater patient satisfaction. We assessed the impact of a policy to increase patients’ adherence to an individual primary care provider or clinic on subsequent use of ED and hospital services in a California coverage program for previously uninsured adults called the Health Care Coverage Initiative. We found that the policy was associated with a 42 percent greater probability of adhering to primary care providers. Furthermore, patients who were always adherent had a higher probability of having no ED visits (change in probability: 2.1 percent) and no hospitalizations (change in probability: 1.7 percent), compared to those who were never adherent. Adherence to a primary care provider can reduce the use of costly care because it allows patients’ care needs to be managed within the less costly primary care setting. PMID: 26153305

Pourat, N, et al. Health Affairs. 2015; 34(7):1113-20.