The Impact of Primary Care and What States Can Do

espite the availability of evidence on the benefits of primary care on population health, little has been done to incorporate this evidence into planning for and evaluation of health services in the United States. In contrast, many industrialized nations have undergone major health system reform to make primary care the essential infrastructure of their health system. Some of these reforms resulted from legislation, as was the case in Spain and Australia, and others have entailed policy decisions to strengthen the practice of good primary care, as has occurred in the United Kingdom (UK) and is now occurring in various aspects of primary care in Sweden, France, and Germany. The reasons the US has not embraced primary care are complex and get to the heart of the characteristics of the US health services system, particularly its increasing dominance by special interest groups such as the academic medical establishment and specialty orientation, medical device manufacturers, and fee-for-service reimbursements that favor specialty practice. 1 In this paper we briefly review the evidence for the impact of primary care in improving health, increasing equity, and reducing total health system costs; discuss the rationale for benefits of a primary care orientation within health services systems; and conclude with a discussion of needed additional research and policy attention. Benefits of Primary Care The first systematic study of the benefits of primary care on health and costs of care consisted of an international comparison of 11 western industrialized nations using data from the mid-1980s. 2 The study was repeated a decade later with 13 countries including Japan. 3 Both studies rated countries on policy characteristics encouraging primary care and practice characteristics reflecting primary care organization: first contact care; person-focused care over time; degree of comprehensiveness within primary care; and coordination of care. The studies were consistent in showing that some countries rated very poorly on primary care whereas others rated better. Those in the former group had poorer health on many population health measures including but not limited to life expectancy at various ages, age-adjusted mortality, and infant mortality (neonatal and postneonatal separately). They also were more costly health systems. These findings were robust and persisted even after controlling for various health-related characteristics of the population (such as extent of risky behaviors in the population). Confidence in the findings was provided by a pooled time series analysis of 18 Organization for Economic Co-operation and Development (OECD) countries that controlled for additional health and health system-related characteristics (such as percent