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For the past eight years, I have been Chief of the Division of Family Medicine at UCSD. We are part of the larger Department of Family and Preventive Medicine at UC San Diego School of Medicine — a group of about 90 faculty whose missions include the delivery of primary health care, the study of population health, social determinants of health, outcomes produced by our health care system, and methods of preventing health problems from occurring in the first place.
Our Division of Family Medicine operates three offices, cares for about 25,000 patients, teaches medical students, and along with our affiliate programs, is responsible for all the civilian family physician training in San Diego.
From where I sit we seem to be poised on threshold of reforming health care and finding a solution to covering all uninsured Americans. I sincerely hope President Obama and our Congress can accomplish this goal as it continues to be highly embarrassing to be the only developed country — some would say the most developed country — without the ability to provide basic health care to all its citizens.
But my concern is more focused at the grass roots of what will actually happen if we do provide coverage to all our citizens. While about half of these individuals’ needs are being met in some regard by safety net free clinics and emergency rooms (and largely inadequately in the latter setting), if this policy change does happen there will be a huge load that will suddenly appear on the doorstep of the state’s primary care docs.
In the state of Massachusetts we have a recent example of what can happen to the demand for primary care services if coverage is extended. There the primary care system has simply been overrun, “next available” appointments are many months out and many PC practices are simply maxed out and have closed to new patients.
Nationally according to most experts there is either a current bare adequacy of PC clinicians for present need or a soon-to-be shortage. With health reform and the sudden influx of 47 million new covered patients that “soon-to-be” shortage will become acutely present in the very near term. According to a recent study by Kevin Grumbach, Arpita Chattopadhyay and Andrew Bindman Andrew of the University of California, San Francisco on California’s physician supply:
“The statewide supply of primary care physicians is around the lower limit of the federally established per capita standard and is markedly inadequate in most California counties … Only 16 of 58 counties meet the minimum COGME (Council on Graduate Medical Education — an advisory group to Congress on US Workforce and Graduate Medical Education issues) standard of an adequate supply of primary care physicians (>60/100,000) and 8 counties have a supply that is less than half (<35/100,000) of the recommended range … In general, rural counties tend to have far fewer physicians per capita than urban counties. Counties in the Central Valley and Inland Empire are particularly likely to have a low supply of physicians. Several rural counties also face the predicament of an aging physician primary care workforce and apparent difficulty recruiting younger physicians to replace their aging workforce.”
Because of twin facts of our ever-growing huge expense on health care (estimated now at 16 percent of GDP or more than $2 trillion a year) and our decreasing standing among industrialized countries in many measures of health status from overall life expectancy to years of life lost to preventable causes to infant mortality — many have concluded that our system needs major repairs. These fall into 3 main categories: insurance coverage, cost-containment and reconfiguring the delivery system. I have already mentioned insurance coverage, but many more millions of Americans are actually under-insured (defined by spending significant amounts of time / yr. without insurance or with insufficient coverage for their medical needs. Fixing this will cost $50-100 billion and the fight will be about who pays: the government (taxpayers), employers or patients.
Cost-control is also a huge issue — and one that if not solved threatens to consume more and more of our GDP to the stopping point of running into other key areas of must-have government/societal spending like police, defense, education, infrastructure, social security, etc. There are many drivers of increasing costs of medical care including the continuous progress of technology producing new drugs, procedures and equipment that can potentially improve care; the natural tendency to expand the use of new inventions beyond their initial purpose and target population; and the poor evidence base for the specific decisions to use specific pieces of the entire diagnostic/therapeutic armamentarium in daily practice. It is estimated that fully one-third of what we as physicians do every day in practice is likely to add NO measureable benefit to the health of our patients. That’s a third of $2 trillion! Helping to fuel this continued expense from the other side of the exam table is the insatiable appetite of the American people for health care. We believe as a society that science can help solve many of our problems, and this belief operates heavily in the realm of health care where we often want to do everything we can that might possibly improve our medical condition. To combat this two-constituency force for greater and greater health expenditures the new American Recovery and Investment Act recently passed by Congress establishes a 15-member commission on comparative effectiveness of medical interventions and the money to support further research in this area. These efforts will help determine which interventions are worth the money and could act as a brake on the heretofore limitless free-market and evidence-less expansion of the application of available technology.
Reconfiguring our health care system is the third considerable challenge that we need to confront. As Tom Daschle described in his Senate confirmation hearings before his appointment went south — we have a system that looks like an upside down pyramid. We spend the most money on very high tech/high intensity interventions first and then spend what’s left on primary care and often run out of funds way too early. All other industrialized countries spend money initially on their primary care foundational services and then spend what’s left on more and more focused, expensive and less proven technologies that affect fewer and fewer patients. Barbara Starfield is a very experienced and insightful researcher of health care systems at the Johns Hopkins School of Public Health. She and her colleagues have demonstrated in numerous studies from many other countries as well as in many geographic areas and at different levels of the US healthcare system that primary care physicians add value to the health care system in terms of access to care, decreased disparities, overall mortality and preventable deaths and decreased cost of overall care. Thus, we need to right that inverted pyramid and create a primary care foundation that is strong, capable of reaching ALL our citizens and able to provide the most cost-effective services that will improve the health of both individual patients, their families and our communities as a whole.
One approach to achieving this goal that is gaining a lot of momentum in Congress as well as at the state level and locally, is the concept of providing a Patient-Centered Medical Home (PC-MH) for every American. This is a medical office where a patient will establish long-term continuity relationships with a team of healthcare providers led by a primary care physician. This team will provide directly 85-90 percent of the patient’s needs and coordinate the remainder of those needs that required more specialized services. The PC-MH will improve the care of those with chronic diseases so that they all received state-of-the-art evidence-based care. This team will also be able to reach out into the community and serve patients where they live and will be accessible by both telephone and internet portals 24/7/365. The PC-MH will actually be responsible for all those who choose it (or are assigned to it as the insurance coverage case may be) and will take a population health perspective by promoting healthy living and prevention techniques for everyone on its entire panel of patients.
Some would say that this is “old wine in new bottles” as this longitudinal continuity and comprehensive care is what family physicians have been doing for the past 150 years. While I agree with this, times have changed and the fluidity of insurance coverage, the mobility of our population and the reduction in the numbers of primary care physicians have contributed to a breakdown in this important continuity relationship. The “new bottles” are also important as they add value to the care primary care docs can deliver. New computerized health records, physicians’ electronic access to point-of-care evidence, electronic prescribing directly to pharmacies, the ability to track entire practice populations and Web-accessible 24-hour communication all have the potential to increase the power of the PC-MH to positively impact health and do it more efficiently.
What we need now is enough primary care physicians to lead such PC-MHs, and this is where additional intervention is needed. It is very important for the citizenry to understand this need so they can support healthcare reform proposals that include measures to increase the output of family docs. I say “family docs” specifically because I am one and because family physicians are the mainstay of the country’s primary care physician output. Most internal medicine graduates are now entering specialty training or becoming hospitalists who focus on patients who end up in the hospital. Similarly, most pediatric graduates are entering pediatric specialties. So the most reliable way to increase the number of primary care physicians is to support the production of family physicians who enter and stay in active clinical practice in primary care over 95 percent of the time.
There are four things required to produce more family docs: payment reform, practice infrastructure and change assistance, training pipeline repairs and research support.
- Payment reform: The current payment structures disincentivize medical school graduates from going into primary care. Because they are now graduating with an average educational debt in excess of $140,000 and they turn to specialties where they can earn so much more by using (or over-using!) highly remunerated interventional technology and procedures.
- Practice Infrastructure and Change Assistance: In order to have a highly functioning PC-MH the primary care physician needs to have an electronic medical record and this involves a significant expense outlay. Changing existing and often conventionally staffed practices into well coordinated, team-based practices that emphasize prevention, community outreach and enhanced patient access is also a challenging proposition. Most authorities who have worked to assist practices in this effort have determined that significant resources must be devoted to the “remodeling” of current practices into the PC-MHs of the future.
- Training Pipeline Repairs: The educational pipeline is currently totally unregulated in our society. This is a derivative of our free-market economic system where workforce policies at the federal or state level are non-existent and the fact that students largely pay for their own medical education. So we have let the market drive this choice and we are unlikely to pass any kind of governmental regulation of training slots. So we will need to manipulate the incentive structures noted above or establish special “tracks” within our medical schools to attract potential students who will more likely become the primary care physicians we need for our new PC-MHs.
- Research Support: And finally, we need a new focus on whole person-centered medical research to complement our organ, molecular and genetic efforts at the NIH. After all, it is whole persons who come to see the doctor and they bring a lot of contextual baggage with them from their family, cultural background and community. It is impossible to do the right thing for a patient without understanding all the forces and influences on them.
In summary, our health care system needs a significant repair job. Primary care — ie. family docs — should play a key role in bringing effective health care to all Americans who will hopefully soon have the means to seek and pay for health care. We will likely commit to having a Patient-Centered Medical Home for each of them. But we currently don’t have enough family docs to populate all our PC-MHs and many of those medical homes are in need of renovation. We need to fix this critical deficit by promoting selection, supporting training and fixing compensation for family docs and by supporting the research base that will make their practices as modern and effective as the rest of our health care technology.