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 Preserving Primary Care: the Front Line in the War Against Cancer

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保留初级保健：抗癌战争的前线

联邦基金最近的一份报告详细记录了美国医疗保健系统以非常高的价格提供令人不安的低质量。1 许多人都在努力获得足够的医疗服务。对于普通大众和癌症患者而言，无法获得医疗服务会影响各个方面的医疗服务——从预防到治疗再到生命终结。人们越来越多地关注这场医疗保健危机的根本原因，并且正在出现解决质量差距的新范式。其中包括侧重于衡量和支付质量而不是护理量。2 获得和质量不足的根本原因之一是缺乏对初级保健的重视。11 证据的权重强烈表明，拥有医疗保健倡导者和中央医疗协调员可改善结果。对于被剥夺权利的人群而言，这一角色可能尤其重要，因为“医疗之家”的可用性为他们提供了通过复杂的医疗和康复过程的导航。人们越来越期望初级保健临床医生监测和支持越来越多的癌症幸存者。12 最后，定期护理对于帮助患者和家属应对临终决定和症状管理至关重要。尽管有惊人的证据表明初级保健临床医生在抗癌中发挥了关键作用，但美国初级保健服务的未来仍不确定。一些备受瞩目的出版物质疑我们是否正面临“初级保健的终结”。13 威胁来自初级保健临床医生的报销不足。同时，HRSA 资助计划的削减大大减少了可用于学术初级保健发展的资助。由于这些经济力量，选择初级保健职业的美国毕业生人数正在下降，初级保健临床医生被迫在更短的时间内进行越来越多的患者就诊。 14 初级保健迫在眉睫的危机护理以及它对我们国家的健康构成的威胁正在引起人们的注意。美国医师学会、美国家庭医师学会和其他组织提出了初级保健提供的新模式。15 医疗保险和医疗补助服务中心是负责制定医疗保险报销政策的组织，已提议修改其费用表；这一修订增加了对初级保健服务的支付。这些举措不会解决我们的初级保健问题，但它们确实为进一步变革提供了动力。癌症护理社区应该如何应对？首先，负责减轻癌症负担的政府和非政府实体必须更深入地了解初级保健对癌症死亡率的影响。二、影响初级保健服务质量和保留初级保健的政策：抗癌前线 已提议修改其费用表；这一修订增加了对初级保健服务的支付。这些举措不会解决我们的初级保健问题，但确实为进一步变革提供了动力。癌症护理社区应该如何应对？首先，负责减轻癌症负担的政府和非政府实体必须更深入地了解初级保健对癌症死亡率的影响。二、影响初级保健服务质量和保留初级保健的政策：抗癌前线 已提议修改其费用表；这一修订增加了对初级保健服务的支付。这些举措不会解决我们的初级保健问题，但它们确实为进一步变革提供了动力。癌症护理社区应该如何应对？首先，负责减轻癌症负担的政府和非政府实体必须更深入地了解初级保健对癌症死亡率的影响。二、影响初级保健服务质量和保留初级保健的政策：抗癌前线 负责减轻癌症负担的政府和非政府实体必须更深入地了解初级保健对癌症死亡率的影响。二、影响初级保健服务质量和保留初级保健的政策：抗癌前线 负责减轻癌症负担的政府和非政府实体必须更深入地了解初级保健对癌症死亡率的影响。二、影响初级保健服务质量和保留初级保健的政策：抗癌前线