Reform, Reform Everywhere and Not a Primary Care Dollar to Drink

In 1993, nipping at the heels of potential health care reform, Franks, Nutting, and Clancy published a paper in JAMA declaring that, “relatively few dollars…have been invested in primary care research.” They go on to state, “an expanded research program examining the organization and process of primary care is essential…”¹ My, how things have stayed the same. Health care Reform is in the air again. Hopefully, by the time you read this we have some definite answers about what that looks like. Both HR 3962 Affordable Health Care for America Act (House Health Reform Bill)² and HR 3590 Patient Protection and Affordable Care Act (Senate Health Reform Bill)³ have passed their respective governmental branches, and are now in committee to iron out the final version. A side-by side comparison can be found at the Kaiser Family Foundation Web site.⁴ How will these 2 bills and health care reform impact NAPCRG and American primary care researchers?

The current health care reform plans both explicitly state the need for a robust primary care system and workforce. Providing coverage does not equal access, and any reform passed will see strong primary care initiatives. MedPAC has testified on the need for strengthening the primary care workforce. The American Academy of Family Physicians has called for additional funds for Title VII and graduate medical education. However, there is very little discussion on the importance of building a strong scientific basis for primary care. Translational research is much more than simply getting the newest drug to market. Primary care researchers understand just how little we really know about the scientific basis for our work, and NAPCRG has always taken a lead in developing and building the scientific basis for primary care. Unfortunately, there are really no solid provisions in the current health care reform legislation that explicitly identify the need for primary care research or provide resources for it. As usual, primary care is viewed as simply a sum of its parts: hypertension care, diabetes management, antibiotic use, organ system after organ system. Or viewed in relationship to access, community health centers, Health Professional Shortage Areas, and increased workforce. There is no explicit understanding or resource for the need to study and learn the best elements or “organization and process” for primary care. While funding access to primary care for millions more Americans, current plans do not include resources to assure that the primary care provided is the best. We need a well-articulated and promoted statement on the unique qualities of primary care and the necessity for a strong research and scientific basis for primary care.

There are a few tidbits in current reform plans that may keep primary care researchers busy for the next few years. Comparative effectiveness research (CER) will see a large infusion of resources, in the range of $400–$600 million per year. Many folks will be able to take advantage of these resources, and hopefully primary care researchers can take a prominent role in CER to help our patients at the point of care. The Institute of Medicine has published its top 100 priority topics for CER, and several of the top 10 relate to primary care, such as the effectiveness of care-coordination programs.⁵ In fact, practice redesign, preparing practices for the medical home, and chronic disease management research will see extensive additional resources. It is unclear how much of this money will be directed to pilot projects run by payors or intermediaries rather than primary care researchers. Hopefully, the Primary Care Extension Model initiative will end up in the final reform bill and this may provide some resources for practice-based research networks (PBRNs) to help practices in their redesign-medical-home efforts. There will be several grant mechanisms to study and implement community prevention, wellness, and behavior research and services. NAPCRG researchers have successfully competed for these funds from HRSA, CDC, and AHRQ. AHRQ has been on the forefront of primary care research and practice transformation, and will continue to lead these efforts. The NIH’s Clinical Translational Science Awards will continue to provide an opportunity for primary care researchers to take advantage of resources geared towards translation and community engagement. Many of these programs will see increased funding providing research dollars to more primary care researchers.

Health care reform is just out ahead of us as the United States considers the opportunity to provide basic healthcare to millions of its citizens. Primary care will be a cornerstone to reform. Primary care research will likely continue to struggle and need to feed off the other biomedical sciences to build a strong primary care evidence base. The Research Advocacy Working Group of NAPCRG will be looking at ways to push the primary care research agenda over the coming year. We look forward to working with many of you to highlight your excellent research and promote the need for a strong scientific basis for primary care.

• © 2010 Annals of Family Medicine, Inc.