General Practice

Primary care: core values Primary care in an imperfect market

John Roberts, staff physician. 

Madrona Medical Group, 4465 Cordata Parkway, Bellingham, WA 98226, USA

johnroberts{at}compuserve.com

Series editor: Mike Pringle

Doctors generally disdain the word "market" when it is applied to the work they do. A market is an encounter controlled by supply and demand.¹ In most markets there is a purchaser, who pays for the specific goods he or she will receive, and a seller, who has the goods and will provide them to the purchaser.

Medicine is an imperfect market. In health care the purchaser is usually not the consumer, and the goods provided by the seller are difficult to define and often contingent on other aspects of care such as results of tests and treatments.² In addition, the medical marketplace does not follow the classic rules of supply and demand. Doctors (to a diminishing extent) set the demand of the care that they will provide and therefore can artificially increase demand for the goods they supply, as highlighted by Roemer's law: "The supply of beds creates the demand for those beds."³

Economic theory also assumes that the buyer-consumer will be knowledgeable about the goods to be purchased and can compare sellers' quality and prices. This is difficult in medicine. Firstly, seller-doctors have until recently controlled all the information about health care. Secondly, consumer-patients tend to avoid using medical services until they need them acutely, and by then, shopping is virtually impossible. Thirdly, even if payer-insurers or consumer-patients try hard to compare seller-doctors and their products, data are expensive to collect and complex to interpret. Finally, in the United Kingdom and in the non-urban and poorer parts of the United States, seller-doctors can set up monopolies or oligopolies in which neither purchasers nor consumer-patients can shop or even easily negotiate services or prices.

Despite these exceptions, it has become increasingly clear over the past 20 years that medicine behaves as a market in many ways. Most obviously, doctors behave according to the rewards they are given. Insurers, whether private or public, can no longer afford unfettered inflation and have become active buyers willing to invest heavily in comparing costs and quality. In the United States, purchasers now have more information on the market than do the doctors who deliver the services. Consumer-patients, too, respond to market incentives. For example, requiring them to pay a small amount (say $10 at the time of medical service) decreases the use of emergency departments by 10-20%. ^{4 5}

	The primary care perspective

Top The primary care perspective From consumerism to managed Five market models Conclusions References

Where does primary care fit into the discussion? Primary care directly accessible 24 hours a day is usually the patient's first point of contact with the medical system. The primary care physician should be the friend, philosopher, and guide of his or her patients, an advocate and protector and coordinator of appropriate specialist services. He or she should provide long term, continuing, comprehensive care. The primary care physician also acts as a health broker. Within the community, primary care can improve the health of the population through helping to remedy social pathologies; providing planned health promotion; screening for risk factors; preventing disease; collecting reliable data on the condition of a community; and helping the community to decide on priorities for health.⁶

The term "health broker" describes how critical primary care is to any sane medical market. A short history of medicine in the United States shows why. In 1940, 90% of physicians in the United States declared themselves "generalists." When the nation went to war, workers' pay was frozen, so medical insurance quickly became popular as a legal way to make jobs more attractive to workers in short supply. By the war's end, most workers were covered by indemnity insurance, which paid doctors for services rendered (fee for service). Not only did this new system reward doctors for testing and treating with little regard to costs, it also rewarded patients for seeing the most expensive doctors. These were usually specialists, who were trained to deal with patients whose probability of severe or unusual illness was greater and therefore required greater expenditures. Such unchecked consumerism led to massive cost inflation, the tremendous expansion of specialty medicine, and the near demise of primary care. By the 1980s only about a third of doctors in the United States called themselves generalists.²

	From consumerism to managed care

Top The primary care perspective From consumerism to managed Five market models Conclusions References

The inflation became so burdensome to employers paying for medical insurance that huge companies were being crippled. Chrysler, during the 1980s, was paying more for medical insurance than for the steel it used for its cars. One remedy was managed care, which had begun 50 years earlier, during the labour movements of the 1930s. In managed care, insurers (usually called health maintenance organisations) pay doctors a prepaid capitation amount for each patient that the doctor agrees to care for. In essence, payment is for people served, not for services delivered. The incentives are the converse of those of fee for service medicine, and they encourage doctors to spend less and patients to see specialists only rarely.

The rise of capitated care has been slow, but in the past 20 years it has come to surpass the fee for service system in primary care. About 55% of Americans are now in some sort of managed care arrangement, and the number may jump to 75% as the government embraces managed care as the preferred public insurance mechanism for the poor (through the scheme Medicaid) and elderly (through Medicare).

In general, primary care physicians in managed care behave much like general practitioners in Britain: they serve as doctors of first resort for nearly all medical problems and act as gatekeepers for patients' access to specialists. With the rise in managed care has come a parallel rise in the demand for primary care; specialists now find it difficult to find work in a nation oversupplied by doctors, while primary care doctors are still in great (though diminishing) demand.⁷ Doctors in training have recognised this new situation and, for the first time in several decades, have in the past four years been choosing the primary care disciplines (family medicine, internal medicine, and paediatrics) rather than specialty training.

	Five market models

Top The primary care perspective From consumerism to managed Five market models Conclusions References

America, as its politicians are fond of boasting, is an experiment, and nowhere is this more true than in medical markets. Nothing about American medical systems is true throughout the country. Los Angeles and its managed care system is both ideologically and geographically a continent away from the southeast, where fee for service medicine still predominates. This somewhat chaotic nation of healthcare systems illustrates how primary care affects various medical markets and how they, in turn, affect the practice of primary care. There are at least four models in the United States, and anotherthe single payer (box).

Integrationist
The integrationist model is the fee for service system that many doctors in America still cling to, particularly in many eastern states. It remains in place, in an attenuated form, for several reasons. Firstly, it is traditional, so doctors and patients (and even insurers, to some extent) are comfortable with it. Secondly, fee for service medicine can draw doctors to rural areas, where recruiting general practitioners is often difficult. Thirdly, managed care does best in urban areas, where people can travel short distances to various competing medical centres.

Fee for service medicine has generally been detrimental for primary care because it rewards oversupply of services and allows patients to bypass the primary care doctor and go directly to the specialist. Obviously, development of community oriented primary care is impossible in such circumstances.

Outreach
The outreach model has become popular with academic and other tertiary centres, with their surpluses of specialists. The primary care doctor's surgery remains the centre of clinical activity, and specialists regularly attend sessions there. Such systems have become common in smaller cities, where there are relatively fewer specialists, and among overpopulated specialties such as gastroenterology, cardiology, and orthopaedic surgery. In the midwestern states, where distances between cities are great, this system has become popular. Major medical schools, such as those in Chicago and Minneapolis, send their faculty members out by aeroplane virtually every day of the week.

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Competitive
The competitive model is common in cities where competition for patients is high, not only between specialists but also between primary care doctors and specialists, and where there are too many doctors. The specialist might tell the asthmatic patient, "Next time you have an attack come and see me directly." Such behaviour undermines the patient's relationship with the primary care doctor or, when the primary care doctor is meant to be acting as a gatekeeper to each specialist visit, creates outright animosity between the doctors.

Managed market
The managed market is where America has been heading and is where primary care becomes a true gatekeeper specialty. It is crucial to understand that in the United States at present, managed care is an extremely competitive and risky marketplace, with more than 1000 insurers trying to sell coverage at lower and lower rates while trying to get doctors to accept more financial risk for patients. The trend now is toward mergers among insurers, which, if carried far enough, will create a landscape that resembles a lot of mini-NHSs.

Single payer
The single payer system, as exemplified by the British NHS, is used throughout the worldexcept in the United States. Variations on the model are as numerous as the nations sponsoring these systems.

	Conclusions

Top The primary care perspective From consumerism to managed Five market models Conclusions References

The marketplace cannot solve the problems of medicine, nor eradicate the tensions between primary care and specialist doctors. Nor can an imperfect model ensure highest quality medicine at the lowest costs.

But in considering primary care medicine and the marketplace, it may be helpful to turn to a failed reform of the American system, that of President Clinton in the early 1990s. His task force, while realising that an imperfect market can never be made truly perfect, did list five criteria for an optimal medical market:

• Universal medical insurance coverage
• Costs that are affordable to society and to patients
• Comprehensive medical benefits
• Freedom of patients to choose their own doctors
• Public accountability, both in cost and in quality of care.

Unfortunately, these five statements are probably mutually exclusive in practice. But they remain a goal for all of us to consider as we continue to reform our own medical marketplaces.

	Acknowledgments

Funding: None.

Conflict of interest: None.

	References

Top The primary care perspective From consumerism to managed Five market models Conclusions References

1. Stoline AM, Weiner JP. The new medical marketplace: a physician's guide to the health care system in the 1990s. Baltimore: Johns Hopkins Press , 1993.
2. Light DW. Health care systems and their financing. In: Walton J, Barondess JA, Lock S, eds. The Oxford medical companion. Oxford: Oxford University Press , 1994.
3. Feldstein R. Health care economics. 2nd ed. New York: Wiley , 1994.
4. O'Grady KF, Maning WG, Newhouse JP, Borrk RH. The impact of cost sharing on emergency department use. N Engl J Med 1985; 313: 484-490[Abstract].
5. Selby JV, Fireman BH, Swain BE. Effect of a copayment on use of the ED in an HMO. N Engl J Med 1996; 334: 635-641[Abstract/Free Full Text].
6. Fry J, Light D, Rodnick J, Orton R. Reviving primary care: a US-UK comparison. Oxford: Radcliffe Medical Press , 1995.
7. Miller RS, Jonas HS, Whitcomb ME. The initial employment status of physicians completing training in 1994. JAMA 1996; 275: 708-712[Abstract/Free Full Text].
8. Greenfield S, Nelson EC, Zubkoff M, Manning W, Rogers W, Kravitz RL, et al. Variations in resource utilisation among medical specialties and systems of care: results from the medical outcomes study. JAMA 1992; 267: 1624-1630[Abstract/Free Full Text].
9. Medical Leadership Council. Report from the frontier, 1997.  Washington: The Advisory Board , 1997.
10. Light DW. Primary medical care: more choice, less cost. Med Care 1996; 34: 985-986[Medline].