Preserving Primary Care: the Front Line in the War Against Cancer
Authors: R. C. Wender
Journal: CA A Cancer Journal for Clinicians (2007)

A recent report by the Commonwealth Fund meticulously documents that the US health care system delivers disturbingly low quality at a very high price.1 Many individuals struggle with obtaining adequate access to care. For both the general public and the cancer patient, lack of access impacts care delivery at every point along the spectrum—from prevention through treatment and end of life. Increasingly, spotlights are being focused on the root causes of this health care crisis, and new paradigms are emerging to address quality gaps. These include a focus on measuring and paying for quality as opposed to volume of care.2 One of the root causes of the access and quality shortfall is a lack of emphasis on primary care. Starfield and others have demonstrated that nations that build their health care systems on a strong primary care foundation achieve lower mortality rates and higher public satisfaction at lower cost.3 Adults with a primary care physician as their personal physician are 19% less likely to die prematurely than individuals who utilize a specialist as their personal physician.4 Primary care availability is associated with a higher rate of early breast, cervical, and colon cancer detection.5,6,7 A recommendation from a trusted source of primary care is the strongest predictor of whether an individual does or does not attempt to give up tobacco.8,9 Primary care clinicians also play a key role in earlier diagnosis for the symptomatic patient and in accessing treatment following diagnosis.10,11 The weight of evidence strongly suggests that having a health care advocate and central coordinator of care improves outcomes. This role may be particularly critical for disenfranchised populations for whom the availability of a “medical home” provides navigation through the complex processes of medical treatment and recovery. Primary care clinicians will increasingly be expected to monitor and support the growing number of cancer survivors.12 Finally, a regular source of care can be vital in helping patients and families cope with end-of-life decisions and symptom management. Despite the striking evidence of the critical role played by primary care clinicians in the cancer fight, the future of primary care services in the United States is uncertain. Several high profile publications have questioned whether we are facing “the end of primary care.”13 The threat derives from inadequate reimbursement of primary care clinicians. Concurrently, cuts to HRSA grants programs have substantially reduced grants available for academic primary care development. As a result of these economic forces, the number of US graduates who are choosing primary care careers is declining, and practicing primary care clinicians are pressured to conduct an ever-increasing number of patient visits in shorter time frames.14 The impending crisis for primary care and the threat that it poses for our nation's health is being noticed. The American College of Physicians, American Academy of Family Physicians, and other organizations have proposed new models of primary care delivery.15 The Centers for Medicare and Medicaid Services, the organization responsible for setting reimbursement policies for Medicare, has proposed a revision in their fee schedule; this revision increases payment for primary care services. These initiatives will not solve our primary care issues, but they do provide a stimulus for further change. How should the cancer care community respond? First, governmental and nongovernmental entities that are responsible for achieving a reduction in the burden of cancer must develop a richer understanding of the impact of primary care on cancer mortality. Second, policies that impact the quality of primary care services and the appeal of primary care careers to future clinicians warrant the focus of cancer care and cancer advocacy organizations. Improving insurance coverage for preventive services is a vital step toward reducing cancer mortality, but taking full advantage of coverage policies will only occur when every American has access to comprehensive primary care services from a reliable, trusted source of care. Primary care clinicians are a powerful force in improving the health of the nation and in the cancer fight. They form a vital link between improved discovery and the timely delivery of high quality care.