As the presidential campaign debate over health care intensified, I heard from seven different friends with the same problem: They had loved ones who had recently moved and, like many others across the U.S., could not find a primary care doctor. Three were in Washington where, according to 2006 data from the Department of Health, 38 of 39 counties report primary care shortages.
Their plight reminded me the candidates’ proposals to expand health coverage are not enough. Americans also need better access to high-quality care that the nation can afford. Unless patients can get in to see the family physicians, internal medicine doctors and pediatricians who provide that first level of contact to the system, we can’t achieve the reforms needed in quality, safety and cost.
An example of potential problems ahead is seen in Massachusetts, which recently instituted universal coverage by way of a new state law requiring residents to have health insurance. Officials originally estimated that 150,000 newly insured people would be seeking care, but the number turned out to be more than 350,000. Now, The New York Times reports that the state’s primary care doctors don’t have capacity to manage the demand.
Such gaps in health care service loom large just as experts warn of provider shortages. “Primary care, the backbone of the nation’s health care system, is at grave risk of collapse,” according to a recent report from the American College of Physicians, the group that represents 125,000 internists.
At the same time, our nation’s population is aging fast and will increasingly require the kind of care that primary care doctors do best: preventing illness and managing chronic conditions. ACP predicts that the country will need 40 percent more primary care doctors by 2020.
Ideally, each person should have access to a primary care doctor for ongoing medical care. Extensive research by Barbara Starfield of Johns Hopkins University and others has shown good primary care helps improve health in populations in a variety of ways, including longer life expectancy and fewer deaths from heart disease, stroke, infant mortality and low-birth weight. The stronger a nation’s primary care orientation, the fewer early deaths from asthma, bronchitis, emphysema and pneumonia. In 2005, Starfield reported that increasing the supply of primary physicians by just one doctor per 10,000 people (a 12.6 percent increase over average supply) could result in as many as 127,000 fewer deaths per year.
Instead, our nation is losing primary care doctors and is falling behind those countries whose systems are based on primary care. Americans’ average life expectancy is considerably shorter than that of Canadians, Japanese and Western Europeans.
A recent analysis of 19 industrialized nations published in Health Affairs showed the U.S. had among the highest death rates from treatable conditions, despite spending the most per person on health care. When researchers looked at improvements between 1997-98 and 2002-03, they found that deaths from treatable conditions in all countries fell by an average of 16 percent. But they called the U.S. “an outlier,” because it showed a decline of only 4 percent. Other countries with primary care-based systems have dramatically outpaced us in terms of how their populations enjoy the benefits of medical progress. If the U.S. had done as well on this measure as the three top-performing countries (France, Japan, and Spain), there would have been 101,000 fewer deaths in our country in the study period, scientists concluded.
How is it that more primary care can make such a big difference? By ensuring that people have a familiar point of initial contact for care, and by ensuring that subsequent care is continuous, comprehensive and coordinated. One especially promising model of primary care is the so-called medical home — practices where physicians lead teams of providers who coordinate each patient’s care across the health system and the community. In this model, providers typically have continuous access to electronic medical records and additional time for visits with those patients who need more counseling and care for chronic conditions. The providers’ teams have the capacity to proactively reach out via phone or e-mail to patients with reminders about preventive care, cancer screening and self-management of problems like diabetes and high blood pressure. Those with certain conditions might be invited in for “group visits” where they can learn from providers and get support from one another.
Medical home models — including one in Bellingham funded by the Robert Wood Johnson Foundation and one at the Group Health Factoria Medical Center — have shown encouraging results. They appear to be reducing costs while improving health outcomes and patient and provider experiences.
But such models rely on a strong primary care labor force and only a third of U.S. doctors work in primary care, down from three in five half a century ago. By comparison, in most other advanced countries, half the doctors are primary care providers. According to 2005 figures from the ACP, one in five doctors who entered primary care in the early ’90s had left the practice.
This exodus has contributed to the shortage and to patients’ frustrations. Coordinating one’s own care can be challenging, especially for older patients with many chronic conditions. They may see a cardiologist for a heart problem, an orthopedist for knee pain and an endocrinologist for diabetes — with no single doctor to advocate for them in the complex system. Meanwhile, more people use emergency rooms for such problems as sore throats and chronic back pain, crowding out real emergencies while missing access to coordinated care.
The U.S. reimbursement system is largely to blame for the primary care shortage. Throughout much of health care, providers get paid more for procedures than they do for “cognitive services” like counseling patients in self-care, helping them make health care decisions and coordinating care among specialists. A specialist doing surgery or a diagnostic test earns two to 10 times more than a family doctor who spends the same time caring for a patient with diabetes or asthma. From 1995 to 2003, while primary care providers worked longer hours, their inflation-adjusted income fell by 10 percent. Of course, they aren’t just in it for the money, but they can do the math; and such disparities make primary care less attractive.
Many primary care providers, in efforts to retain their incomes, have become more like entrepreneurs than physicians. Some have set up “boutique” practices, catering to wealthier patients who see value in paying a premium to be guaranteed more comprehensive care that results in better health outcomes. Others have dropped out of primary care altogether and now work in a growing number of specialized settings such as day-surgery clinics. Some have simply picked up the pace, crowding more patients and procedures into their schedules. As a result, they have less time for quality interactions with patients and they’re living a high-pressure, workaholic lifestyle that few would recommend. New doctors get the message. Since 1998, more than half of all family practice residency positions have gone unfilled.
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