Michael Wulfers, MD - President

 

 

 

 

The Crisis in American Primary Care Medicine

Primary care medicine is currently in a state of crisis in this country. In 1979 when I graduated from the University of Missouri School of Medicine 35 out of 110 graduating doctors chose to pursue a career in family medicine. This included some of the best and the brightest in our class. In contrast, only 4 out of 85 graduates from my alma mater chose a career in family medicine in 2007.

Unfortunately, this is not just a Missouri phenomenon. In 1998 there were nearly 3300 accredited United States family medicine residency positions offered---of which 72% were filled with U.S. senior graduates. In 2008 not only are there 650 fewer residency positions offered, but only 41% were filled with U.S. graduating medical students. (1) The figures for general internal medicine and general pediatrics are just as bleak. The AAFP has estimated that in order to care for our rapidly aging population the U.S. will need 40,000 more primary care physicians within the next decade. Growing need, shrinking supply---it doesn’t sound like a good combination, does it?

The American health care system is nearing a crisis of monumental proportions due to three major problems. These are: problems with access, problems with cost, and problems with quality.  We all know that 47 million Americans have no health insurance. However, if our primary care infrastructure continues to crumble, even having health insurance will not guarantee access to good, affordable care. Take Massachusetts as an example. Since 2007, when the state of Massachusetts mandated that everyone carry health insurance, 340,000 of 600,000 uninsured citizens have procured coverage. Many are now, unsuccessfully, searching for a doctor. Waiting times for a preventive exam with a primary care physician are up to one year in some parts of the commonwealth. This has happened in a state which ranks well above the national average in the per capita supply of physicians. (2)

When it comes to health care Americans are paying Mercedes prices, and getting a Yugo in return. Sixteen percent of our total economy is spent on health care, more than any other nation. Yet, when the American health care system is compared objectively with other nations, our results are mediocre, at best. Using five performance indicators to measure health care systems in its 191 member nations, the World Health Organization ranked the United States 37th. (3) Among the members of the United Nations the United States ranks a pedestrian 29th in life expectancy.(4) So, what can we learn from studying other health systems?

The common denominator among the health care systems which outperform us is a strong emphasis on primary care. Most other industrialized nations have a ratio of primary care to specialty physicians of 50/50. In contrast, only 31% of American physicians are trained in a primary care specialty (family medicine, general pediatrics, and general internal medicine). Multiple studies, many of which were conducted by Dr. Barbara Starfield at the Johns Hopkins School of Public Health, have shown that countries whose health care system is built upon a strong primary care base have both lower costs and healthier populations. (5)

But, you might ask, do these generalizations also apply to the United States? Starfield found that even within the U.S. states having a higher ratio of primary care physicians to population had better health outcomes and lower overall mortality rates---and, generally, at less cost. This data was valid even when income inequalities within the states were taken into account. (6)

The North Carolina Medicaid experience provides a valuable “laboratory experiment” which could, and probably should be applied nationally. In late 1999 Community Care of North Carolina (the North Carolina Medicaid program) adopted a primary care/medical home based model of care. Physicians are paid 95% of the Medicare rate (in contrast to about 65% of Medicare in Missouri) for fee for service office visits. Additionally, a $3 per patient monthly management fee is provided. The enhanced payments to primary care physicians have allowed private practice physicians to participate in the program----in contrast to Missouri where we lose money on every Medicaid patient we see. Enabling primary care physicians to manage and coordinate the care of these indigent patients has resulted in fewer ER visits, fewer hospitalizations, and has reduced unnecessary medical expenses. Since 1999  it is estimated that the state of North Carolina has saved one half billion dollars by instituting this program. More importantly, the health  of its population  has been significantly improved. (7)

Most of us would agree that without major reforms health care in the U.S. is headed for disaster. The current direction of American health care is not sustainable. Unfortunately, most government leaders, both state and national, have a poor understanding of the nature of our health system’s problems. For example, the health care plans of both presidential candidates address only access to care. They offer no solutions for the other two major problems which we face—high cost and mediocre quality. Any comprehensive reform is doomed to failure without strengthening the foundation upon which all successful health systems are based--- primary care medicine. Shifting to a primary care model may not be the only reform needed---it may not, in itself be sufficient---- but it is an absolutely necessary part of any plan to heal our current dysfunctional system.

So, what must we do to save primary care medicine from extinction, and revitalize our healthcare system?

First and foremost there must be drastic changes in the way in which physicians are paid for their services. For years updates in the Medicare fee schedule have been made based upon the advice of an AMA appointed committee called the Relative Value Update Committee. Private insurance companies soon follow suit. There are 29 positions on this committee---and only 3 are allotted to primary care specialties. Is it any wonder that physician payment schedules are so skewed toward procedural activities? You get what you pay for----and since cognitive and management skills are significantly undervalued compared with procedural skills U.S. medicine has evolved to the point where it is easier for a well insured patient to get an MRI than it is for others to obtain basic preventive services. The AAFP’s proposal for physician payment reform, like that of Community Care of North Carolina, includes a patient management fee in addition to fee for service payment. This would at least partially reimburse primary care practices for the physician time and practice overhead spent in directing patient care outside of the traditional office visit. These services are currently provided for gratis.

We must reverse the trends of the past 15 years and once again recruit the best and the brightest American students into primary care medicine. We want students who are attracted to primary care because they value the intangible rewards gained from a lifetime of service to ones’ patients----not those with primarily pecuniary interests. However, under the present circumstances the financial disincentives for choosing family medicine, general internal medicine, or general pediatrics are substantial. Currently, the average debt of a graduating senior medical student is $120,000 (public school) to $160,000(private school). (8) No wonder students are flocking to Radiology, Anesthesiology, medical and surgical subspecialties where they not only make 2 to 3 times as much, but also work fewer hours than in primary care. Both state and federal governments need to do much more to ease the financial burden on students who would like to pursue a career in a primary care specialty. I believe the MSMA, MAFP and MAOPS should push our state legislature toward a fully funded program which would forgive the loans of any student who completes a primary care residency and then locates his/her practice in Missouri.

There are some promising signs that payment reform may be coming. On April 9, 2008 the Medicare Payment Advisory Commission, or MedPAC endorsed two key recommendations that, if approved by Congress, would shift the focus of the Medicare program toward a more primary care based system. The first proposal calls on Congress to increase payments for services provided by primary care providers. The second proposal advises Congress to initiate a three year, $400 million medical home pilot project to improve health care quality and reduce costs. Additionally, the AMA appointed Relative Value Update Committee has, to its credit, endorsed the concept of paying medical homes a monthly management fee in addition to any regular pay for Medicare services.(9) However, these proposals still have to make their way through Congress, with the potential for them to be amended, possibly to our detriment, in the process.

Physicians are still some of the most respected individuals in our respective communities. We need to take the time to speak with our patients, state and federal elected officials, and industry leaders about the present crisis in American medicine. More than likely, they don’t have a clue about what is really going on. In particular, our federal representatives and senators must be urged to support the MedPAC recommendations.  We, as individuals and as organizations, must get the word out-----the best bargain in the U.S. health care system is a well trained primary care physician!!

However, before advocating any position involving health care reform, I believe we must first do a litmus test. That test is to ask, “Is this in the best interests of my patients?” I truly believe that the reforms I have advocated are not only necessary  to save primary care medicine-----but are also essential in order to insure the health and well being of the American citizenry in the 21st century.