Lower cost of care, improved health through access to more appropriate services, reduction of inequities in the population's health and reducing disparities in health across population groups are benefits of primary care according to Dr. Denotrah Archer Cartwright.
The future of primary care -- health care provided by the doctor who sees the patient first and provides basic treatment and who will determine whether a patient needs to be referred to a specialist -- is basically the future of health care according to family medicine specialist Dr. Denotrah Archer-Cartwright.
With the spotlight focused on the term primary care more and more with the ongoing discussion and impending launch of National Health Insurance (NHI), Dr. Archer-Cartwright who practices primary care daily said people should know what primary care really is, the future of primary care as medical professionals see it worldwide, and how it will impact Bahamians.
She sought to give a better understanding of what primary care is, and how the medical field is changing in The Bahamas at the recent Doctors Hospital Distinguished Lecture Series.
"According to the American Association of Family Practitioners, primary care is care that is provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with an undiagnosed sign, symptom or health concern. This is not limited by the problem of origin, organ system or diagnosis. These are the persons when you first enter the healthcare system would be the ones to take care of you, and they would be the ones to not only diagnose you, but follow up on your care and to be able to coordinate on your care."
The family medicine specialist said primary care refers to health promotion -- disease prevention, health maintenance, counseling, and patient education. A large part of primary care, she said, is patient education and getting people to understand about their health, disease processes and understand what they can do to live a healthier lifestyle.
Primary care involves diagnoses and treatment of acute and chronic illnesses in a variety of healthcare settings. Physicians collaborate with other healthcare professionals to create a plan for a patient. Those patients with a problem outside the scheme of primary care are referred to a specialist to ensure they get particular tests done, which she said is all based on a patient-centered model as the medical community moves away from looking at the disease process itself, but actually centering their care on the patient and the patient's needs. And done with a coordinated efficiency.
Primary care benefits
Lower cost of care, improved health through access to more appropriate services, reduction of inequities in the population's health and reducing disparities in health across population groups are benefits of primary care according to Dr. Archer-Cartwright.
"Healthcare is better in areas where there is a primary care physician. Studies have found that people who are seen by primary care physicians are basically healthier. In the 1990s they realized that with a higher ratio of primary care physicians to the population there were better health outcomes. There were lower rates of all causes of mortality and this was for non-communicable diseases like heart disease, cancer, stroke, and a decline in infant mortality."
According to Dr. Archer-Cartwright, in England they found that the standardized mortality was lower due to having family physicians and general practitioners. She said an increase of one primary care physician per 10,000 in a population, basically improves the outcomes of health by 5.3 percent. And just by improving primary care services, the United States (US) has estimated that 127,617 deaths per year could be averted through such an increase in the number of primary care physicians.
The concept of primary care basically came around in the 1920s when there was a report written in the United Kingdom (UK) which made primary care the new cornerstone of healthcare. The concept she said was happening around the world -- except for in the US which actually has a 20th Century approach and is into more specialized care -- while the rest of the world was embracing the concept of primary care.
Dr. Archer-Cartwright said the Institute of Medicine (IOM) started looking at a more integrated system. They wanted accessible healthcare services for clinicians and wanted them to be accountable. They wanted to address the large majority of personal healthcare needs, and develop a sustained partnership with patients. She said with the idea of practicing in the context of the family and the community, they have seen the emergence of practice where it's more centered on the patient, rather than on the diagnosis.
"In the past medicine was you had a problem, we diagnosed the problem, we treated the problem. But now the concept of bringing a more integrated system came about where you were in actual partnership with the patients, as well as to take into the context the community and the family and things in the environment."
Who's a primary care physician?
Primary care doctors take on the responsibility of providing patients with comprehensive healthcare, so they're doing chronic disease prevention, acute care, inpatient and outpatient settings, so they have additional training after their initial medical degree and do more time studying and a residency. They're not limited by problem origin, organ system or diagnosis. They are like a "one-stop shop" in terms or primary car.
Dr. Archer-Cartwright did an additional four years of focus on primary care learning after she finished medical school.
She also described primary care doctors as advocates for their patients.
"Because of the training, these are the physicians that would advocate for policies, advocate for your health, would put into context all of the things in the community related to health and how we would better serve the public and population's needs. They are coordinators of the entire healthcare system and basically looking to benefit the patient."
According to the doctor in this model there is room for physicians who are not trained in primary care specialties. She said although more focused, they might deal with aspects of prevention, health maintenance, acute care, chronic care, rehabilitation, but that it's usually not as comprehensive as when you're dealing with a primary care specialist. She said specialists are usually supposed to be in close consultation with a fully trained primary care physician. In the model there are other persons involved other than physicians -- nurse practitioners who have done additional study, physician assistants, as well as other allied healthcare providers, like physiotherapists who are going to be involved in putting together and coordinating a patient's care.
"It's a collaborative team effort and is led by a primary care physician."
World leaders
Worldwide, Dr. Archer-Cartwright said France is currently the leader as to the country with the best healthcare system and the best primary care system. The United States is ranked at 36 -- Jamaica is 53 -- Barbados is at 46. The Bahamas is at 94.
In determining world rankings Dr. Archer-Cartwright said the overall health of a nation, health equality and how people were able to access care, responsiveness to that care and equality and fair financial contributions in how it's financed and paid for was taken into account.
"France is so good, because they are extraordinarily open and communicative with patients and families which reaps significant patient safety benefits, as well as they have more doctors per capita. They are open to this model of primary care and focusing on families and community more so than just disease processes. They have high private and public coverage, so insurance coverage in France is about 95 percent of the population whether it's public or private.
"They are very efficient in spending their money -- they spend a lot on healthcare, and use that money wisely, so this brings about a low death rate. They have 23,000 general practitioners [GP], most of them are all self-employed, and citizens are free to go to whoever they want as their GP, so they have this open system where you can go and find whichever GP you want, and basically between public and private insurance, it's taken care of. A part of the comprehensive approach is to have that personal doctor you can go to all the time, and they just pay a flat rate of 23 francs [approximately $23] and that is actually given back to them, because they already pay into the healthcare system. Most of the doctors in France have a contract with the government, so basically everybody can get on board with the government system and you can see just about any doctor in France."
When it comes to healthcare, Dr. Archer-Cartwright said the US spends more money than everyone else in the world, but also has some of the highest rates of death amenable to healthcare per 100,000 population. That, she said, was ascertained through a study done with 19 countries. She said the US death rate due to healthcare practices is twice the number in France.
"They're spending way more money but aren't getting the benefits of all that money they're spending, not like a lot of other countries. And their focus wasn't primary care. Their focus was specialized care. Failure to emphasize primary care was their problem. So they are now moving to this shift of primary care being the foundation of their healthcare system."
New models and the future
The new model that is the medical home in which doctors and different specialists work as a team to give the care that's needed Dr. Archer-Cartwright said showed positive results in the US.
"They saw better intermediate quality outcomes from just doing primary care medical homes, and additionally adding electronic medical records. US adults who have a primary care physician have 33 percent lower health care costs, and 19 percent lower odds of dying than those who see only a specialist."
As a nation, she said they came to the conclusion that they would save $67 billion each year if everybody used a primary care provider as their usual source of care.
The doctor said the future of primary care is focused a lot on the patient-centered medical home and close partnership between clinicians and patients as well as looking at the complexity of the healthcare system.
In order to change the system, she suggested, some feathers would have to be ruffled.
"You're going to have to change the culture and the way that you do things -- removing inefficiency, bringing in technology and that requires innovative leadership, and that is what is going to drive changes in healthcare in the future."
Goal, challenges and technology
The overall goals for primary care is to improve health care outcomes, reduce the expense of healthcare, reduce the frequency of emergency room visits, avoid hospitalizations and reduce costly move for patients later in life and a healthier nation. With that goal in mind the doctor said the demands of the low income set also has to be met if primary care is going to be effective as everybody has to be able to access it.
While a lot of people want to go into specialties, in The Bahamas specialists and family care physicians are needed, she said.
The doctor also described technology as both a blessing and a curse.
"You have 'robotization' coming up where they are actually trying to replace some of the things that doctors and care providers do, with robots, and you're seeing in some areas where they're using less physical examination, but using diagnostic as the only tool. Here in The Bahamas we have a strong clinical focus to our practice, so I don't think that's really a challenge here."
On the flip side she said technology has been found to create better patient care as electronic medical records can reduce errors, improve patient safety as well as support better patient outcomes. She said it also improves risk management and prevents liability actions from happening, improves public health outcomes and the quality of patient care overall. She said telemedicine is an important took in the Bahamian archipelago.
Why primary care is needed
Dr. Archer-Cartwright said primary care is needed in The Bahamas because the top causes of death in the country are ischaemic heart disease (13.3 percent), HIV/AIDS (13.2 percent), stroke (8.9 percent), diabetes mellitus (6.5 percent) and hypertensive heart disease (6.2 percent) -- diseases that really need preventative care.
"We have a high infant mortality rate, low utilization of essential services and high rates of cancer."
From a National Health Insurance [NHI] report she said it was ascertained that in The Bahamas over $2,000 per person was being spent on healthcare, and that when compared to other places in the region, The Bahamas was in some instances spending more than five times more per person.
"Just like the Americans, are we getting bang for our buck? Our life expectancy is about 75.5, when you have a country like Costa Rica that is spending about $943 and their life expectancy is 79.3. So we're spending, but what are we getting for it? The life expectancy in France is 81 years. They have 34 physicians for every 10,000 population; ours is 13."
Dr. Archer-Cartwright said with one in three Bahamians not having any type of health insurance, it's a problem the government is trying to correct with NHI, a program that it is said will ensure all legal Bahamian residents -- no matter their income, age, island of residence or current health status -- can receive healthcare free of cost at point of service; cost for healthcare is paid for in full or in part by the government.
"So some of the concepts for NHI are pretty positive, and falling in line with the rest of the world and how they're changing their healthcare systems. Yes the government would be funding in terms of paying out the money to persons, but the money has to come from somewhere. Now the initial investment for NHI is about $100 million and that's for primary care and they say that's going to be no cost to you. But in order for primary care to work properly, there's so many other elements that need to be working as well, so if you're talking about quality primary care that means you need to have all those other components functioning properly, and that's going to cost you money."
NHI versus universal healthcare
The family medicine specialist said the goal should be universal healthcare and access and quality healthcare for everybody. But she said NHI is only a component of universal healthcare, because all of the components will be needed to make it work.
"The good things about NHI and how it's changing the landscape of healthcare in the country is basically pushing that primary care is first. So they recognize that the foundation to a good healthcare system is having a good primary care system. The problem the US had was efficiency, so these are all good elements, but we also have to look at how efficiently we're going to get these things done. So the concept of NHI is actually pretty good and pretty progressive and they do embrace this whole idea of a patient-centered, community-centered approach. Dr. Delon Brennen, NHI project manager said 'The goal of NHI Bahamas is simple: it's about a better, healthier lifestyle for Bahamians.'
"So this sounds great, and exactly what we're talking about; however you need the policies in place to drive this, the proper funding to drive this, and you need proper patient education. So these are really good components they're talking about and if we were just to go on the model that they suggest we would have a better healthcare system.
" Now the efficiency and management of that we have to be cautious of that, because right now we currently waste about 25 percent of everything that we spend on healthcare, and we're talking about putting more money in without kind of fixing the systems that are driving it. So that's a cautionary tale that we have to look at, because we don't want to be like the US where we're spending more money and not getting bang for our buck."
Dr. Archer-Cartwright said primary care is essential to the future of healthcare, and that The Bahamas will want to have equity in health and to use primary care to address co-morbidities and multiple morbidities that are being seen in the population.
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