Thursday, December 11, 2008

A Quality Health System Needs More Primary Care Physicians

“Health care reform in Massachusetts has led to a dramatic increase in the number of people with health insurance. But there's an unintended consequence: A sudden demand for primary care doctors has outpaced the supply.”
--NPR’s “All Things Considered”, November 30, 2008 (

A national health system will need to cover everyone, as I have discussed, but it must go farther. The goal is not simply to “cover everyone”, but to provide universal access to high-quality, cost-effective health care. To do this, we need the right mix of health professionals, practicing in the right locations, and a payment system that reimburses them for providing the care we want and need. Our population is poorly served in many areas, particularly rural and inner-city areas; our physician workforce now has too few physicians practicing in these areas. Twenty percent of the US population lives in rural areas, while only 9% of physicians practice in those areas, and an even smaller percentage of medical students is planning to practice in these areas. The main specialty needed in rural areas is primary care, particularly family medicine but also general internal medicine.

Having more primary care physicians is important beyond the need to supply doctors to underserved rural and urban areas. A past article (December 5) cited the recent Commonwealth Fund health scorecard, which shows we are on the wrong track, with the US’ scores dropping from 67 to 65 out of 100 from 2006 to 2008; of note is that our worst score is for “efficiency” (53/100), the area where primary care has the greatest impact,[1] although we can also expect primary care to improve our poor performance on “access” and “equity.” The Fund’s scored indicators for “efficiency” include: Potential overuse or waste (duplicate medical tests, tests results or records not available at time of appointment, received imaging study for acute low back pain with no risk factors); ER use for condition that could have been treated by regular doctor (hospital admissions for ambulatory care–sensitive (ACS) conditions); Medicare costs of care and mortality for heart attacks, hip fractures, or colon cancer; Medicare costs of care for chronic diseases: diabetes, heart failure, COPD; Health insurance administration as percent of total national health expenditures.

Virtually all of these conditions are improved by having a greater primary care infrastructure. Extensive work has demonstrated that health systems built around primary care, both in this country and abroad, provide higher quality care at lower cost. When people have a provider who is “their doctor”, not the doctor for a piece of them, or one disease, a doctor who can coordinate, manage, and refer appropriately, who is available to them when they are needed, then people’s health is better and the system is more effective. This data is extensively documented by Baicker and Chandra from Dartmouth[2], Starfield, Shi and Macinko from Johns Hopkins,[3] [4] Ferrer, Hambridge and Maly[5] and others.

Baicker and Chandra looked at cost and quality in Medicare patients by state, and found that states with higher Medicare spending had lower-quality care. In addition, states with more primary care doctors had higher quality and lower cost, while those with more specialists had higher cost and lower quality. [Click on the graph to see it more clearly.]

Starfield, Shi and Macinko note that “Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care.”
They also note that “The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.”

They posit six mechanisms why primary care has a beneficial impact on population health:
--Greater access to needed services,
--Better quality of care,
--Greater focus on prevention,
--Early management of health problems,
--The cumulative effect of the main primary care delivery characteristics, and
--The role of primary care in reducing unnecessary and potentially harmful specialist care.

In addition to these strong population health arguments for a primary care infrastructure, there are also the direct benefits to individual patients. People should have a provider who cares for them, the whole person, and understands their health in the context of biology, social situation, psychology and in the context of their family and community. The primary care provider (terrible word, but while it will most often be a doctor it could also be a nurse practitioner) knows the patient over time; the epistemology of the doctor-patient relationship in primary care is longitudinal, rather than acute or episodic. Ferrer and colleagues identify several primary care functions for individuals: “…although not unique to primary care, a strong emphasis on person-focused care projects beyond the patient–physician dyad to support important system goals such as quality of care and efficient use of services. Person-focused care also helps caregivers reach decisions that meet the needs of the patient rather than the health care system. This entails careful consideration of procedures that may be driven by availability rather than benefit; self-perpetuating cascades of diagnostic or therapeutic interventions; and interventions aimed at reducing clinician rather than patient uncertainty.”

The big problem, however, is that we have a shortage of primary care doctors and that problem is getting worse. The number of students entering family medicine residencies has been dropping precipitously. Between 5% and 10% of family medicine residency programs have closed in the last several years, and those that are left are able to fill less than half their positions with American allopathic (MD) graduates. Osteopathic (DO) graduates make up some of the rest, but the bulk are filled by graduates of international medical schools, including US citizens who go to medical school abroad. These students may have even less internal motivation to practice in rural areas than do US graduates, although there is a program that allows foreign nationals on J-1 (student) visas to stay in the US if they practice in an underserved area. General internal medicine, another primary care specialty, has seen even a greater decline. Residents completing a 3-year internal medicine residency may enter primary care (or become a hospitalist; see blog entry December 4, 2008) or may enter subspecialty training, such as cardiology, gastroenterology, or pulmonary medicine. Garibaldi, writing in Academic Medicine (the journal of the Association of American Medical Colleges) in 2005[6], found that while 54% of internal medicine 3rd-year residents were planning to enter primary care in 1999, in 2005 it was only 27%, and only 19% of 1st-year residents. In a July, 2008 study in JAMA that got a great deal of press coverage, Hauer and colleagues found that only 2% of graduating medical students from 11 US medical schools were planning careers in general medicine.[7] For the US to have the primary care workforce it needs, the factors encouraging medical students to not choose primary care careers will need to be addressed; this is the subject of a future entry.

[1] “Why not the best? Results from the national scorecare on US health system performance, 2008”, Commonwealth Fund, Jul 2008,
[2] Baicker K, Chandra A, “Medicare spending, the physician workforce, and beneficiaries’ quality of care”, Health Affairs on line, W4-184, 7 Apr 2004.
[3] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502
[4] Shi L, Starfield B, Kennedy B, et al. ”Income inequality, primary care, and health indicators.” J Fam Pract. 48(4): 275-284, 1999.
[5] Ferrer RL, Hambridge SJ, Maly RC, “The essential role of generalists in health care systems”, Annals of Internal Medicine 2005;142:691-699.
[6] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12
[7] Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64

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