Primary Care Attributes and Mortality: A National Person-Level Study

Annals, BMJ, JAMA and other journals have been correct to diagnose the Primary Care Medical Home or Pay for Performance as not the highest expectation solutions that primary care leaders have promoted.

Pediatrics was incorrect to allow the unrevised publication of an article promoting the primary care medical home as the solution for children without special needs. The authors selected characteristics related to continuity that also selected out social determinant demographics and characteristics that resulted in better health care outcomes.

Annals published this article that claims benefits for primary care. At least the article does note missing co-variates and the potential for demographics and characteristics to influence better outcomes.

We should be thankful for articles that continue to support social determinant indicators. We should correct articles that claim too much benefit from "continuity" or "primary care" or the "medical home." Apparently concepts such as physicians accepting too much of the credit and getting too much of the blame are hard-wired into the design at the current time and all the way to the most prestigious reports.

At some point there should be some realization that claims of quick cure solutions are delaying efforts that would address health access, rising costs, and quality problems. A nation that can no longer solve problems by generically spending more or generically expanding workforce must figure out specific solutions.

The case can be made that health care spending multiple times greater per person in zips with top concentrations of health workforce (and education and income, etc.) shapes better outcomes in health and other areas while lower health spending per capita in 30,000 zip codes with 65% of Americans shapes lowest access and decreased quality along with significantly less economic impact (and other indicators of lesser concentration).

At a minimum any real solution will require health spending diverted from locations with top concentrations of workforce to locations with lower to lowest concentrations. At a minimum any real solution will require more spending on basic services and this will have to come from spending on most costly specialized services.

Failure to understand the American people and their characteristics, distributions, and demographics can result in distorted perspectives that can delay or prevent real solutions.

Churchill had no idea regarding how right he was about the American ability to delay real solutions. As long as we continue to focus on innovation, creativity, and reorganization we will continuously delay the blood, toil, tears, and sweat required to improve the care of most Americans behind by design. It bothers me to think of so much accomplished 1965 to 1980 by those who recovered and restored family practice and so little accomplished 1980 to the present.

Since it is consistently the patients of family physicians that most need the solutions, this is perhaps the most tragic of all.

Solberg LI, Asche SE, Fontaine P, Flottemesch TJ, Anderson LH. Trends in quality during medical home transformation. Ann Fam Med. Nov- Dec;9(6):515-521.

Long WE, Bauchner H, Sege RD, Cabral HJ, Garg A. The value of the medical home for children without special health care needs. Pediatrics. Jan;129(1):87-98.

Competing interests:   None declared