Is a good family doctor one who treats your knee pain and manages your recovery from heart surgery? Or is it one who refers you to an orthopedist and a cardiologist?
Those are questions at the heart of a debate about primary care – one with serious health and financial implications.
A study from the American Academy of Family Physician's Robert Graham Centersheds some light on this topic. The findings, published in the latest issue of Annals of Family Medicine, suggest that family doctors who provide more care themselves save the health system money.
The researchers looked at 3,652 family physicians and 555,165 Medicare patients across the country. They found that patients of physicians who provided a wider range of services experienced fewer hospitalizations and incurred lower health care costs.
"Patients were 35 percent less likely to end up in a hospital if their family doctor was very comprehensive, compared with a doctor who was minimally comprehensive," says Dr. Robert Phillips, of the American Board of Family Medicine and one of the authors of the study.
The researchers also found that doctors who performed a wider range of services reduced overall patient costs by between 10 and 15 percent.
"That is a huge bending of the cost curve," says Dr. Kevin Grumbach, chair of family and community medicine at the University of California, San Francisco, who wrote an accompanying commentary. "This probably trumps any other innovation in terms of reducing Medicare costs."
Medicare costs and overall health care costs have been rising rapidly in the U.S. for decades, consistently outpacing economic growth. Part of the reason, Phillips says, is the increased use of specialists. Roughly 80 percent of all physicians in the U.S. are now specialists, according to the American Association of Family Physicians. That's up from 70 percent 15 years ago, and is far higher than most European countries.
Grumbach says the new study confirms a belief that had long been suspected, but has rarely been proven: Coordinated care, led by a family doctor who is judicious about referring patients to specialists, leads to cost savings.
"It goes from a matter of philosophical preference to actually showing that this saves money," Grumbach says.
Grumbach notes that the study doesn't address one important concern: quality of care. The researchers weren't able to track patient outcomes or collect data on patient experiences. So it's possible that the care received from primary care doctors was inferior, and that the cost savings weren't worth it.
"But it's also possible that the opposite is true, that these patients received better care," Phillips says. He notes that several recent studies have shown a link between more hands-on primary care and better patient outcomes.
Grumbach says future research should aim to determine where money is saved. Which primary care interventions are saving money without compromising quality? He says this will become especially important as the Affordable Care Act puts more pressure on doctors and hospitals to improve quality and reduce costs.
But for now, Grumbach says, the message of this study is clear: "Pay for quality primary care because that is the most efficient," he says. "It's not that complicated."