Expanding primary care means healthier communities

By Dr. Mark Fourre | Oct 01, 2020
Dr. Mark Fourre

Years ago a Dartmouth College researcher named Jack Wennberg, using claims records from Blue Cross Blue Shield of Maine, discovered a difference in the rate of hysterectomies performed in Lewiston and Wiscasset in the 1970s. In Lewiston, nearly 70 percent of women under age 70 received hysterectomies. In nearby Wiscasset, the rate was a fraction of that. Wennberg had discovered variability in the rate of hysterectomies based on location.

With the disparity identified, Wennberg then looked at health outcomes. Were the women of Lewiston, with their high rate of hysterectomies, healthier than the women of Wiscasset? The answer, it turned out, was no. This and other data led Wennberg to conclude that the vast majority of hysterectomies in Lewiston were medically unnecessary. Soon after, the Maine Medical Association gathered doctors from around the state to discuss Wennberg’s findings. This self-scrutiny changed the way doctors thought about hysterectomies, and Lewiston’s rate dropped dramatically. And not just Lewiston’s. Today, very few hysterectomies are performed anywhere in Maine.

The important lesson of Wennberg’s work is that variability is quite common in health care and, inevitably, one approach produces a better outcome than the others do. In some cases, that means it produces healthier patients. In other cases, it produces equally healthy patients but at a lower cost. Although this is a somewhat oversimplified explanation of Wennberg’s work and the Maine Medical Association’s response, it helps us understand that identifying variability is the first step toward improving our health care system.

Our vision at PBMC and Waldo County General Hospital is to make our communities the healthiest in America. So, what variables might we address locally to fulfill that vision? If we are to be driven by data – and I think we should be – the answer seems clear. We should focus our work around good primary care.

A primary care provider is a patient’s first contact with our system. They manage the patient’s health care on an ongoing basis and provide most of their care. When a specialist is required, the primary care provider coordinates that care.

Researchers have focused on primary care since the 1990s, and the data shows that communities with a higher ratio of primary care providers per total population are healthier compared to those with a lower ratio. This holds true across the United States and in every other country studied. In England, the mortality rate for people ages 15 to 64 years of age is lower in areas with a greater supply of “general practitioners.” Spain saw a significant drop in death rates associated with hypertension and stroke after reorganizing its health system to focus more on primary care. In Costa Rica, infant mortality dropped after the country increased access to primary care. The evidence is overwhelming.

Moreover, the health benefits of expanded primary care extend to a broad cross-section of the community, including those who historically have had difficulty accessing the health care system – the poor, the uninsured and the homeless.

In other words, the data tells us that we can improve the health of Knox and Waldo counties and expand health equity by hiring more primary care providers. In fact, the data shows that an increase of just one primary care provider per 10,000 of population produces a meaningful improvement in a community’s health.

At PBMC and WCGH, we recognized this opportunity years ago and began taking concrete steps to increase primary care in the communities we serve. In 2016, we built the Biscone Building on the campus of WCGH to house an expanding primary care practice in Waldo County. Since then, PBMC and WCGH have hired a combined 20 primary care providers, including family practitioners, general internists and pediatricians. We now have 54 primary care providers – 29 at PBMC and 25 at WCGH – ready to serve a combined population of 85,000 residents in Knox and Waldo counties.

More recently, we started construction of a new Health Center on the campus of PBMC. We were motivated to build the Health Center for two reasons. We wanted to bring all of our primary car practices under one roof so that providers could better collaborate to deliver even better care to our patients. We also needed more office space and exam rooms to accommodate all those new primary care providers we have hired.

All this underscores our commitment to expanding primary care as the best way to increase the health of our coastal communities.

And yet, the arrival of COVID-19 back in February revealed that there remains much work to do. For example, we suspended in-person patient visits during the early days of the pandemic and instead cared for patients through telehealth visits conducted primarily by video conference. For most patients, this worked extremely well, and we were able to meet their basic health care needs despite COVID-19.

But some of our patients did not have access to a computer or the high-speed internet connection that makes a videoconference possible. The infrastructure was unavailable to them, especially if they lived in a rural area, or they lived on limited or fixed incomes and simply couldn’t afford a smart phone, tablet or internet service. COVID-19 had revealed a variable in our local health care system: Those who had internet service during the early days of the pandemic had better access to health care than those who did not.

Unfortunately, no number of primary care providers could have remedied this. We must find another solution; one that will require partnering with internet providers and state and local government.

This experience served as a reminder that there are no panaceas in health care. The data clearly shows that expanding primary care is the best way to have the biggest impact on the health of our community. However, it will require other creative and innovative solutions to ensure that no one falls through the cracks.

Dr. Mark Fourre is the President of Pen Bay Medical Center and Waldo County General Hospital.

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