Saturday, August 14, 2010

Spain: an unlikely primary care model for the U.S.

When U.S. health reformers were looking abroad last year, the health systems of Canada and the United Kingdom were the most commonly mentioned. In this blog, I've also compared our primary care to better-functioning systems in more out-of-the-way places: the former Soviet republic of Kazakhstan and the tiny island nation of Taiwan.

An article in the August issue of the journal Health Affairs took a closer look at the reform of the primary care system in Spain that began in the mid-1970s. Following the end of the Franco dictatorship, Spain moved rapidly to reorganize the way it provided health care to its citizens. Not only did it formally recognize family medicine as a distinctive medical specialty, Spain's central government dedicated public funds to guarantee primary care access within "Basic Health Zones" that were "organized around a single primary care team ... [to] coordinate prevention, promotion, treatment, and community care activities." They set a goal to establish a primary care center within a 15-minute drive of any residence in the country, and in 2007, 97 percent of all primary care visits were recorded on electronic health records.

The resulting health gains were impressive. Spain's life expectancy in 2007 was 84.3 years for women and 77.8 years for men, both considerably better than the U.S.'s 80.7 years for women at 75.4 years for men. And like other nations that have organized their health systems around primary care, Spain spends a much smaller fraction of its gross domestic product on health care than does the U.S.: just 8.5 percent compared to 16 percent.

Can lessons learned from the transformation of Spain's primary care system be applied to the U.S.? My answer is yes and no. We have made some recent, though comparatively modest, investments in strengthening the training of primary care physicians, and there are new incentives for physicians to accelerate their adoption of health information technology. In terms of access, it may always be difficult to recruit and retain talented physicians in rural underserved areas, as a recent Washington Post story illustrates. But improving the health of the country certainly won't happen if political leaders don't make universal primary care access - distinct from universal insurance coverage - a high priority over the coming decades.


  1. Dear Kenneth, I am a spanish family doctor. Our secret is that we are "low cost" doctors. We have a fixed income, attending around 2.000 patients listed. With 25 years of experience, 77.000 US dollars and the cost of living is not so different.
    Best regards

  2. When you answer "yes and no", it appears to me that you then only give the "yes" part, and also intrinsic problems that are not reasons to follow the Spanish model. Other than VBV's issue, which is about cost, not quality, what are the "no"'s?

  3. Brazil is making progress with a similar team model compared to Spain. The model maximizes the potential primary care delivery for each primary care graduate.

    The US changes have resulted in less primary care delivery for each primary care graduate, making shortages of primary care workforce even more problematic.

    UK health care site access and financial access designs are not bad, but the health care quality is limited by lowest child well being in nearly every rating, just like the US. The US and the UK remain last and dead last in child well being measures in Unicef rankings of wealthier nations. Better birth to age 6 shapes all patient care decisions (made by patient), shapes health care personnel quality, shapes employment, shapes a better citizen, etc.

    Japan does not really have a primary care career focus, but the front line physicians in office settings have better support and are dominate the panels that determine accreditation, health spending, and training. Japan also has universal access with a 30% co pay, just 2 plans, and a federal, prefecture, municipality sharing of funding, sites, and workforce. Even so, Japan needed a permanent health access school to meet increased gaps in workforce (Matsumoto, Inoue).

    Japan has top child well being as do most nations that have top quality in health care.

    The correlation between US health care quality state rankings and various individual or grouped child well being state rankings are 0.7 to 0.88 - far beyond the lesser correlations of any primary care to quality relationship.

  4. The US has the opposite design for cost, quality, and access. Social determinants impair health care quality in the US dating back to birth. Divisions magnify the differences across multiple categories such as income,education, health outcomes, health care funding distributions, primary care distributions, and more. Those that become US health workforce are least like those in need of health care delivery erecting more barriers in patient relationships and in designs of important areas such as health access.

    In the US there is no plan for 15 minute access (translated to local or adjacent zip code primary care) - even when the rapidly increasing older and oldest populations require it due to losses of mobility and transportation with age. Since the older and oldest Americans are most likely to be found in locations with shortages and since they double or triple their primary care need with age, and since Medicare primary care reimbursement is insufficient, the shortages of primary care are magnified where primary care is most needed.

    The current design is the opposite from the 1970s design for the US in Medicare and Medicaid with improving health access due to expanding health care coverage, sites, and primary care workforce. The US design changes have been in the opposite direction from health access since the 1970s and divisions have added millions each year to those left behind in one or more aspects related to cost, quality and access. Meanwhile 30 years of US leaders have been promising more health care while failing impressively in progress in understanding even the basic health access required to deliver more health care where health care is needed.

    Health access in the US is the weak link and primary care workforce is the weakest link of all (basic RN nurses, PC clinicians) and 60% of primary care and five of six sources are concentrated in 3400 zip codes in 4% of the land area. These zip codes are clustered together and represent the only adequate primary care coverage locations - a worst possible design for health access for the nation.

    It is impossible for less than 40% of primary care workforce to address the needs of 65% of the US population found in 30,000 zip codes,

    especially when these zip codes include even greater proportions of the most complex populations

    But there are solutions including those sharing origins with the 65% left behind and family physicians.

  5. Family physicians are found at higher levels serving the older, oldest, most in poor health, lower income, poor, near poor, least covered, CHC, lower income immigrant, rural, different languages and cultures, lowest health literacy, least educated, and least employed - Ferrer, Rosenblatt, Mold, Bowman) along with those most likely to become family physicians who arise from the 65% left behind at higher levels.

    The complexity of basic health access delivery is magnified in locations with the least health spending and resources and facilities - the 30,000 zip codes with 65% of the US population.

    These are locations that depend upon primary care services for 35 - 100% of local workforce

    and these are populations and locations that depend upon health care services reimbursed or funded at lowest levels, including primary care services, rural health services, and health services for underserved populations.

    Family physicians and the fewer NPs and PAs remaining in the family practice mode in practice are found distributed at 53 - 60% of active graduates serving this 65% of the US population left behind.

    Family physicians despite the numerous obstacles noted
    1. stay 95% or greater in the family practice mode associated with optimal permanent primary care, rural, and underserved contributions
    2. stay 80% in primary care or 2 to three times higher levels than other primary care sources
    3. arise equitably from all populations, including those left behind
    4. distribute equitably to all populations, especially those left behind
    5. deliver 5 to 8 times more primary care than NP, PA, and IM training program sources - the sources with 21,000 of 27,000 so called primary care graduates that enter primary care at only 30% levels and depart in the years after graduation.
    6. will deliver 40% of future primary care workforce with only 10% of graduates
    7. are more likely to remain in the states in most need of primary care - a best investment by these states in future workforce and future primary care workforce for the state
    8. will likely remain the only unexpanded primary care workforce with only 3000 annual graduates per year, the same compared to 1980 levels.

    Mainly because health care access and primary care are understood so poorly with other solutions promoted to the nation that are less likely to work or that will not work.

    This is magnified by failure to understand the full effectiveness of the basic child well being and basic early education and basic health access solutions that really work for a more efficient and effective nation.

    And the result has been delays in truly preventing the need for national recovery and delays in addressing national recovery in cost, quality, and access in health care and other national components.

  6. Thank you all for these insightful comments. I tend to think that the U.S. will have a harder time than Spain implementing a similar model if that's ultimately the direction we go in, due to resistance from FPs (and their organizations) who traditionally have supported a privately financed, we're specialists-not-generalists model of primary care. It's possible that a two-tiered system might emerge with publicly financed/salaried and private-access fee low-cost concierge (eg Seattle's Qliance) models competing for patients.