Can Primary Care sustain Quality Healthcare for All?

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A comparative analysis in the context of developed; and developing states

Primary care medicine was established to provide essential treatment for common medical problems. It is primarily the modern version of a concept introduced based on the perception of the underlying societal principle of twentieth-century Chinese literacy and rural reconstruction advocates, Y.C. James Yen and Liang Shuming. Primary care medicine, in reality, is nothing but the bureaucratic title given to those physicians who choose to provide the most basic, yet broader scope of skillset towards the health and well-being of a given community. But, today, the title primary care medicine is misleadingly used for a kind of practice that is neither medical at it it’s eternity nor common to the traditional physician job description.

The notion of primary care medicine initially started after the declaration of the Alma-Ata international treaty hosted by the World Health Organization (WHO) under the title of” Health for All.” The health for all is the inspirational derivative of what was initially introduced by James yen in 1920. The major focus of primary care medicine is disease prevention, accessibility to medicine, and reducing healthcare spending. However, decades after its clout, primary medicine is anything but cheaper and evenly distributes. Nevertheless, it is a common belief that there is still a shortage of primary doctors.

Hypocrisy in 21st-century medical practice is overwhelming, yet its prevailing double standard by dodging preventive care from subspecialties on to general practice along with administrative labor of value-based reimbursement is a subject of separate controversy.

Most of us would agree; Prevention is always the best medicine, as treatment must always be accompanied by preventive educational initiatives. In contrast to what said, assuming all the tasks must be enclosed under one title sounds ludicrous.

Primary medicine has been fundamentally expected to be of the low cost for the countries healthcare market, meaning that the Value of a given service delivered by a primary doctor is less than that if provided by a specialist. Latter is the reflection of one thing, and only one thing; that is quality mistakenly is dependent on a title and not a particular skill! Primary care medicine is an epitome of government licensing monopoly of the professional job market to create shortcut solutions. It was established to provide necessary treatment for common medical problems, but the advent of a merit-based physician reimbursement model leaves no basicness in the job description.

A random glance at primary care practice success across the world

The United States has been the frontrunner in implementing primary care practice. Yet, it has faced significant backlash through increasing physician burnout and unsustainable even distribution across the socioeconomic and geographic boundaries. The countries only government-administered healthcare coverage branch; the Center for Medicare and Medicaid (CMS) recently outlined a proposal under “DELIVERING VALUE-BASED TRANSFORMATION IN PRIMARY CARE.” The CMS Primary Cares Initiative is to Empower Patients and Providers to Drive Better Value and Results. The plan not only fails to simplify the physician task but makes their future burdensome. The main focus of this invitation is about facilitating inducements that will heighten the scope of the primary care practice responsibilities under the contingency of improvement in compensation and or reduced administrative workload, which reflects the fact that under this strategy physician or healthcare provider is subordinate to the “primary care practice.” It will empower the medical practice and reimbursement but burden the physician. A recent report published in news medical life science categorizes primary care challenges into- the lack of choice, the variability of the quality of medical care, Reactive vs. Proactive Decisions, Physician Shortage, and Addressing the Challenges. It claims as there is a multitude of challenges facing primary care, they are not adequately identified and addressed. One of the main aims of primary concern is for patients to have a trusted practitioner to talk about any symptoms or health matters before they become critical that would need expanded remedy with additional risks. Numerous of the management decisions in primary care proceed with reactive decision making rather than proactive. Therefore, some of the obstacles could be prevented if proactive decision-making was more sweeping.

According to an article published in BMC health services research – Policy analysis of the Iranian Health Transformation Plan in primary health care (HTP), there’s little attention given bestowed to Primary medicine. Although the drive was intended for stimulating the formation of effective universal care (by boosting the Iranian health policy) this is especially prominent during the first phases of policy development, a gap that occurred because politicians were in great haste to fulfill a campaign promise.

In another publication According to the findings of comparative study despite indications to the success of health systems around the world, it seems that the implementation of decentralization of the government in some sectors and at different levels of health care services is the best option for improving the health system within Iran. Hence, states that the primary health care and referral system by family physicians must be done with regards to the privatization of Healthcare reform management in leading countries, through delegation and paying for the services of the private sector under the supervision of the government and ministry of health, treatment, and medical education. Also, medical service packages, programs, and policies should move towards focusing on prevention and primary care to decrease the traffic of the next levels and reduce the costs. Concomitantly- Tabriz Health Services Management Research Center introduced a study protocol in 2017 to assess the effectiveness of the Health Complex Model in the Iranian primary health care system. The reform, according to the report focuses on the faulty Iranian traditional primary health care (PHC) system. Although proven to be thriving in some rural regions, however, the system is still facing significant challenges in providing PHC services in urban areas, especially the slum urban regions. The Iranian health reform focuses mainly on implementing the PHC system. Hence, The Health Complex Model (HCM) was chosen as the preferred health reform model for this purpose. The intervention phase of the protocol was launched in 2018. It is noteworthy that both types of research support the expansion of public education, patient empowerment, and providing optimal logistics. The first study also corroborates the need for administrative decentralization. It is also imperative to acknowledge that both studies correlate increasing costs of health care, growing expectations of the people, limited resources, and mistrust of the people on government’s poor governance, corruption, lack of inefficiency. Study knowledge that; since in most low to middle-income countries, primary healthcare is provided by the municipal sectors, facing restricted resources, huge costs, and inferior quality of services, politicians, and health policymakers are compelled to formulate kind of disruptions that would meet the citizens demands focusing on enriching the satisfaction of physicians and healthcare providers instead of blanched objective and subjective outcome.

German healthcare is facing its own particular set of challenges, specifically for primary care. For instance, according to a publication by British medical journal the access to a general practitioner (primary care physician) hinges on individual factors and neighborhoods. In Germany, the underserved area is negatively associated with accessibility, controlling for settlement patterns, and several unique elements. Underserved Area and settlement structure also have a significant negative relationship with utilization; that is why the government is controlling the facility distribution through strict licensing practice. The German doctors shut their doors to state insurance patients at the end of each quarter to save money, a new study has shown. Germany’s profit-driven health care system is increasingly attracting criticism. State health insurance patients are striving to see their doctors towards the end of every fiscal quarter, according to another study released. Coordinated care, access to healthcare and efficiency of healthcare delivery are among the challenges that German primary care is facing. Because of the universal nature of Germany’s health insurance policy, enormous tension exists among primary physicians, resulting in more extended average waiting periods for appointments than in the United States. Not surprisingly, waiting periods for specialized care are not longer. The 4th highest health expenditure per capita in the OECD ($4,218 or 11.6% of per capita GDP) Germany shares similar challenges as of the United States and Iran.

Related Article: Primary care medicine: A clinical specialty, or managed care travesty

Iran and Germany; both have universal healthcare coverage. Demographic changes like the aging population and increase in the elderly proportion of the population will drive up demand and cost for health care services, leaving little foreseeable odds for easy cost constraint techniques between the three states. It is even more vital to appreciate the fact that Iran existing as a developing country and the USA alongside Germany holding a top rank among the most economically prosperous nations; all lack the proper logistics of an effective healthcare delivery system. Yet only one of the latter has ever considered politics, government interference in the healthcare system, as well as the centralized nature of top-down policies as being counterproductive towards establishing evenly distributed effective healthcare delivery. That is according to the Tabriz Health Services Management Research Center. One significant advantage of the German healthcare system over others is where Patients have free access to select and physician within the German system. They are only obliged to pay each quarter 10 EUR for the initial doctor visit at a provided practice. They are not required to reimburse if referred by a physician. In fact, according to the statement when patients requested, they generally obtain referrals without restrictions from nearly all primary doctors and specialists. So it does not matter whether they first contact a General practitioner or a specialist. Waiting times to see a doctor are usually moderate, and trust in physicians is very high in the realm, meaning upholding patients’ consumerist expectations is one of the critical factors of primary care success even in government-run programs. The latter privilege is extremely limited within the US managed care sphere and affordable care act. It is also reasonable to state; such flexibility is only feasible in the face of the country’s strong economic stature. Nevertheless, Germans are known to openly protest about their problem, and this is also true for primary care doctors. Yet, at the other end of the spectrum, according to another article German doctors periodically halt scheduling appointments to patients covered under the state, particularly towards the end of every quarter to save money. Based on later research attributed, Germany’s state health insurance policy only allows reimbursing the full cost of specific doctor visit up to a particular volume of patients or an individual financial value.

Related Article: Nordic social program to welfare state capitalism: Two resorts distant from free-market capitalism

More regulations are not the answer

The tasks to fulfill the mandate are not necessarily science-based. In fact, they are the conclusion of multifaceted rhetorical overtures by mainstream politicians. Sensible, evidence-based legislation that honors the fundamental role of a free- competitive market can provide vital public benefits. That includes creating accessible quality healthcare for everyone, yet, despite the promising motives, government regulation frequently disrupts the marketplace picks winners and losers among companies or technologies prejudice. When regulators behave this way, they invariably cause un-consenting damages. The concept of primary care medicine is an example of such a decision process. It is Counterproductive to physician practices because it rests the entire burden on doctors who elect to practice general medical aptitudes but refuse to do so due to heightening workload and pressure. Primary care practice in the United States equals to an outing to Physician burnout.

The commonality of policies among the US, Germany, and Iran

Even though overwhelming socio-political discrepancies exist among the three countries, healthcare system policies on unifying the healthcare access amidst citizens irrespective of the socioeconomic and geographic status of the nation are comparable. All assume expanding primary care practice to rural and slump urban areas through mandatory redistribution of physicians and wealth will solve the 21st-century healthcare crisis; without considering that politicians have been uttering on and about the topic without winning robust perseverance. An administrative solution, like the primary care distribution of physicians, will work only within the fact of substantial economic wealth and redistribution in a populist societal structure like the one we witness in Germany. Even that model is far from perfect. With the prevailing system of merit-based reimbursement, the expanding score of primary care job description would only fuel the polarity of the medical profession.

Within the terms of expanding the administrative scope of the physician profession under the title of primary care implies opening the door to hidden political agenda through cost reduction for the establishment at the expense of the individual physician weigh down.

So who should take the responsibility of primary prevention and Merritt-based reimbursement?

Primary care medicine is a wastebasket of the medical domain. The physician practicing in the field must carry the burden of gatekeeping for other specialties while accepting the ever-increasing protocol-driven preventive care; besides, maintaining excellent rapport with patients.

The most reasonable solution is to maintain individual identity, be it physician or patient irrespective of title. Uphold the skills that any individual possesses and allow referral based on physician and patient judgment. Meaning- redistribute tasks amidst all specialties and subspecialties by giving skills back to their primary proprietors. The answer must make physicians and stakeholder’s missions focus on high-level validation, authorization, and clinical decision making. Concomitantly prevailing solutions must make technology do the hard labor but with 100% transparency on its operations from algorithms to data. Make patients in charge of those decision-making processes and maintain a virtual connection between them and stakeholders at all times. Last but not least, lend data ownership to individual owners.


Adam Tabriz, MD Dr. Adam Tabriz is an Executive level physician, writer, personalized healthcare system advocate, and entrepreneur with 15+ years of success performing surgery, treating patients, and creating innovative solutions for independent healthcare providers. He provides critically needed remote care access to underserved populations in the Healthcare Beyond Borders initiative. His mission is to create a highly effective business model that alleviates the economic and legislative burden of independent practitioners, empowers patients, and creates ease of access to medical services for everyone. He believes in Achieving performance excellence by leveraging medical expertise and modern-day technology.

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