Primary care is critical to the success of population health
Population health has become a pivotal strategic focus for health systems and large provider organizations in the United States as they strive to improve quality of care and reduce costs for the entire patient care journey and focus on maintaining health and well-being of the patient population through preventative care – not just acute care.
A recent study demonstrated the urgency of improving population health efforts to reduce the number of unnecessary and costly use of hospital resources: almost half (47.7%) of all medical care received by Americans between 1996 and 2010 was delivered by emergency departments highlighting the lack of appropriate primary care services that can keep patients with non-emergency conditions out of hospital. And the percentage is increasing steadily.
Many health systems and provider organizations are expanding their primary care and out-patient services to improve their population health effort, in some cases by acquiring primary care practices and making independent physicians employees of the health systems. While this strategy aims to improve preventative patient care, increase consistency and quality of the patient experience and reduce clinical variations, it creates a challenge for many physicians who feel they lose their freedom to practice medicine. This is particularly concerning given the rising challenge of burnout among physicians as reported in numerous recent studies.
The Danish health care system represents a very different model for population health. Policy experts in the U.S. often tout the Danish health care model due to its single-payer, taxpayer funded financial structure that provides equal access to care for all Danish residents. However, the more interesting feature of the Danish health care model is the unique organization of primary care.
The Danish model for primary care
In Denmark, all residents are provided access to a primary care physician of their own choice. The service of the primary care physician is free of charge and the doctor acts as the gatekeeper to all health care services. Danish primary care physicians operate as independent contractors for the Danish health regions, which gives the Danish PCPs a high level of freedom in the way they practice medicine. This model of independent practice has also shown to be very cost-efficient for the health care system and the regions that fund primary care. The physicians own and run their practices as a private venture, remain personally invested in their business and have incentives to make them more efficient. Even more importantly, it provides the individual patient with a trusted, consistent coordinator of their care.
Similar models with independent general practitioners operating based on agreements with the health authorities exist in the other Nordic countries, Sweden, Norway and Finland, and in the United Kingdom.
The Danish primary care sector is an essential foundation for the successful Danish health care system that delivers quality of care at a level equal to the U.S. health care system, but at a significantly lower cost and with equal access to care for all residents.
The Danish primary care services are subject to negotiation between the organization of the practicing physicians and the Danish regions that provide the health care services in Denmark. A new agreement was recently approved by both parties after several months of negotiations and will take effect from January 1, 2018, running through December 2020.
New innovations in the Danish model
The new Danish primary care agreement entails some new innovative steps designed to improve the primary care services for the Danish population:
- Primary care physicians will gradually take over the treatment of patients with type 2-diabetes and COPD (chronic obstructive pulmonary disease). This is in line with many studies documenting that patients with such chronic diseases have better outcomes when care is provided in primary care vs. hospitals.
- The control of certain cancer diseases will be done in primary care.
- Primary care physicians will have greater responsibility for vulnerable patients after discharge from hospital.
- Home visits by doctors to patients will be a higher priority.
- Primary care practices will focus more on ensuring the quality of patient care. In the future, all practicing physicians will be part of so-called quality clusters that will work on reducing clinical variations and ensuring consistent quality of care based on documented clinical quality measures. The clusters will meet regularly to work on the quality of care in their own practices as well as collaboration with other sectors in the health care system.
- Data for assessment of the quality in the physician practices will be provided by academic researchers with expertise in primary care. The new program for data-driven quality improvement through the quality clusters addresses a common criticism of the independent primary care entrepreneurial model that there are too large variations in the quality of clinical care.
What U.S. health care can learn from the Danish primary care model
The Danish primary care model should be a great source of inspiration for the U.S. health care system that is undergoing necessary change:
- Primary care is essential to ensuring population health along all stages of the patient care journey, avoiding unnecessary hospitalizations of patients and offering services to more vulnerable patient groups.
- With growing aging and multi-morbid patient populations, hospitals will not be able to carry the burden of care in the future, and many chronic conditions, such as type 2-diabetes, COPD, chronic heart failure, etc., will be managed better and more efficiently in primary care outside of the hospital.
- Making physicians employees often take away their motivation and incentives to engage in their practice. Other models for better connecting primary care services with secondary hospital services should be pursued while maintaining the independent nature of physician practices.
- Primary care physicians should be given more responsibilities, resources and financial incentives to play the important role of coordinators of care for patients.