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The Future of Population Health
Centennial Issue Population Health Primary Care
Kurt C. Stange
William L. Miller
Rebecca S. Etz
May 26, 2023
May 2, 2023
Apr 25, 2023
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In widely quoted ecological analyses, primary care is associated with population health.1,2 Not only with population health,3,4 but with health equity,5,6 health care quality,7,8 and lower health care expenditure1,4,9,10—a pretty good definition of value.11 Yet, there is a paradox about primary care.12 Despite these desirable population-level attributes, at the disease level at which we typically measure, incentivize, and organize the work of health care, when assessed with one-disease-at-a-time quality measures, primary care does not perform as well as care focused on a single disease.
What is going on here? In caring for patients’ individual diseases, primary care appears to offer lower quality than specialty care. But at the population level of countries, systems, and municipalities—if we organize around primary care, we get better health, equity, quality, and value?12,13 How can this be?
Apparently there are some emergent properties of primary care in which a relationship with the whole—person, family, community—is more than the sum of its parts.14,15 Not understanding this paradox, indeed feeling threatened by it, leads us to act on many potential health drivers in ways that do not have the intended effects on the health of people and populations and that indeed often make things worse.15–17
This paper explores the ways in which primary care might influence population health by serving as a force for integration18 across the often fragmented systems19 influencing population health. In the course of that exploration, we will examine the complexly related mechanisms by which the craft of general practice, as a vital component of primary health care, leads to the emergent properties of health, equity, quality, and sustainable resource use. Then, we will consider two informative stories—one of a person living with multiple chronic conditions and social disadvantage, and a second person who is overserved and whose problems and opportunities do not fit neatly into little boxes. Next, we will examine how primary care might helpfully interact with the other influencers of population health investigated in this special issue of Milbank Quarterly. We close with policy recommendations for federal, state, and health care system leaders.
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