Time, access, and continuity: unleashing the power of primary care

In a recent editorial coauthored with the editors of six other US family medicine journals, Dr. Sumi Sexton, American Family Physician’s editor-in-chief, highlighted the established benefits of having continuous primary care. These include higher screening rates, fewer emergency department visits and hospitalizations, and lower costs of care for patients with chronic diseases. A 2020 systematic review found that better primary care continuity is associated with lower all-cause mortality. A retrospective cohort study​ of more than 100,000 adults in 48 Dutch general practices suggested that the benefits of continuity increase with longer duration: people registered with the same practice for greater than 5 years had lower odds of urgent hospital admission and lower hospital costs.

How does continuous primary care achieve positive impacts on health? Dr. Sexton and colleagues wrote:

The beneficial impact of primary care on population health likely reflects the core functions of primary care, including continuous relationships, whole-person care, better access, better quality, a greater focus on prevention, more appropriate and cost-effective testing, and early management of medical issues. Yet there is little emphasis on these core principles and continuous care in the quality measures to evaluate health care.

Paying primary care physicians based on value rather than volume of services, also known as value-based payment (VBP), is intended to promote wellness and improved health outcomes. However, Dr. Jeffrey Millstein observed in a commentary in the Journal of General Internal Medicine​ that misaligned VBP incentives sabotage effective primary care by reducing appointment access, impairing healing relationships, and discouraging medical students and advanced practice providers from choosing primary care careers:

What does the VBP-influenced primary care workday look like? It begins with a schedule overcrowded with perfunctory wellness visits that require excessive documentation. Visits that satisfy metrics crowd out access for patients with more acute symptoms or other concerns that cannot wait for weeks or months. … Diagnosis code suggestion pop-up alerts are now a constant distraction. … Capturing illness severity matters, but the current state is eroding PCPs’ ability to focus on the concerns patients bring to the exam room.

Access for patients is important, but so are sustainable clinician workloads. Medicare billing data suggest that family physicians require an average total time of 26 minutes per office visit, including non–face-to-face work. Based on this figure, Dr. Clark Trapp estimated in an FPM article that a sustainable workload for a full-time clinician is 20 patient visits per day and a panel size of 1,354, considerably lower than the current average of 1,727. Evidence demonstrates that reduced visit time pressure is associated with more comprehensive care​, particularly for patients with three or more chronic conditions. In contrast, primary care physicians with overloaded schedules who chronically experience “time scarcity”​ report disillusionment and dissatisfaction and cope by ordering unneeded testing, placing unnecessary referrals, and triaging sick patients to urgent care and the emergency department rather than seeing them in the office.

Sufficient time, access, and continuity are essential to unleashing the power of primary care to improve and maintain good health. Missing any of these elements greatly diminishes that power.

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This post first appeared on the AFP Community Blog.