Boost Primary Care For Better, Cheaper Health Care

Just hours before President Obama is set to address Congress and the nation on his plans for a health overhaul, the New England Journal of Medicine pulls out the smelling salts.


A pair of bracing commentaries published online says the time for change has come, so don't blow it, politicians.

In one of the pieces, two defenders of Britain's National Health Service concede its flaws, but say the jewel in its crown is "the strength of its primary care and its general practitioners," something the US would do well to emulate. Primary care doctors cost less and spend less than specialists, which the US has oodles of. So learn from the NHS, they say, and beef up primary care while pruning specialty care.

How do you throttle back on those specialists? Well, try what the UK does, with its National Institute for Health and Clinical Excellence, essentially a "transparent, rule-based evidentiary form of health care rationing." The alternative, they say, is the US style which relies on exclusion of the poor and the vagaries of "perverse incentives" for physicians.

The domestic argument for health-care overhaul comes from some Dartmouth doctors who spend a lot of time looking at the variations in care and its cost around the US. Health status is an important factor in differences in health spending, but doesn't explain the vast majority of the discrepancies. Discretionary decisions by doctors, such as ordering another test or hospitalizing a patient when, are the big problem.

Ultimately, these docs, like their British counterparts, argue for better primary care, with incentives for doctors to provide the most cost-effective care. That approach sometimes means taking the time to explain why a test isn't appropriate or waiting to see if a patient's back gets better without an MRI or surgery.

A change for the better can be made without rationing, these doctors say, citing the experience in some parts of the US already. The idea is to "reorganize and improve care to eliminate wasteful and unnecessary services."



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