Background: The United States currently faces great challenges in primary care, particularly when the Patient Protection and Affordable Care Act (ACA) greatly expands the health insurance market.
Objectives: To (1) discuss key areas where primary care needs to be strengthened, including advanced models of physician reimbursement, chronic disease management, and improved patient adherence to medications, and (2) to review initiatives applying evidence-based medicine (EBM) where positive changes have in fact occurred.
Discussion: This article discusses initiatives that have implemented EBM as their model for change and presents interviews with primary care experts to support the growing need for change in primary care. To improve the quality of care and reduce costs, more needs to be done, particularly by fostering the number of primary care physicians (PCPs) and other healthcare professionals in PCP offices, as well as adjusting payment methods that much more strongly support and reward the primary care and the patient-centered medical home (PCMH) models. An additional area where substantial improvements are needed involves inner-city, rural, and other underserved populations. Provider- and managed care–driven changes are taking place, but much more needs to be done, particularly as a result of the ACA-associated health insurance enrollment expansion. Innovation in payment for PCPs and PCMHs (and corresponding changes in care delivery and improvements in clinically significant outcomes) will be key factors toward the successful implementation of ACA changes. In addition, several examples are discussed, in which the flexibility of managed care and its results-driven orientation are crucial factors for success. Future initiatives that will likely be more challenging and will require significant government funding include the US underserved populations and incentives to encourage medical school students and residents to choose primary care as a specialty.
Conclusion: More innovation, particularly related to realignment of financial incentives to strengthen primary care, is needed to meet America’s growing healthcare quality and cost challenges.
Am Health Drug Benefits. 2012;5(1):40-47
With total health insurance costs at approximately 17% of the US Gross Domestic Product,1 a rapid growth rate, rising rates of chronic diseases, such as diabetes, and an aging population, changing the dynamics—the fundamental drivers—of the US healthcare is key. The 2010 Census estimates 16.3% of Americans do not have health insurance, and that the percentage of people with employment-based health insurance decreased from 56.1% in 2009 to 55.3% in 2010.2
The employment picture is also weak. In 2010, 16.2% of the US population was either unemployed, had temporarily given up searching for a job, or was working part-time while looking for full-time employment.3 A national survey of employer-based health insurance showed that average premiums for family coverage in 2011 totaled $15,073 (9% higher than in 2010), with employer contributions of $10,944 and employee contributions of $4129.4
In addition, the United States faces strong headwinds from the weakness of the international economy, a financially led downturn that tends to last longer and be deeper than other recessions,5,6 and hyperpartisan politics. The need for accessible, affordable health insurance will be even greater in 2014 than it is now.
This article reviews the current shortages in primary care physicians (PCPs) and other healthcare professionals that must be greatly ameliorated before the major expansion of the US health insurance system in 2014, when the Patient Protection and Affordable Care Act (ACA) provides health insurance alternatives to individuals and to businesses with 50 or more employees. The article also discusses several examples of transformative initiatives in the US healthcare system that have been shown to improve the quality and lower the cost of care. Figure 1 depicts the key ways in which the US healthcare system may need to move forward to meet these challenges.7-11