Monday, May 30, 2011

Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center


Bob Phillips MD, Executive Director of the Robert Graham Center, the American Academy of Family Physicians’ (AAFP) DC-based policy center, gave one of the plenary speeches at the recent annual meeting of the Society of Teachers of Family Medicine (STFM). His talk, available at the Family Medicine Digital Resource Library ( presented a great deal of data regarding the current, and anticipated future, state of the US primary care workforce. There are currently 222,308 primary care doctors (FPs, GPs, general internist, general pediatricians and geriatricians), or one for every 1358 people, and an additional 86,000+ NPs and PAs in primary care, for a total of about 308,000, or about 1 primary care provider for every 1000. This is not a bad ratio, looking at the nation as a whole, but geographic distribution is another matter, with the ratio of primary care providers (PCPs) to person ranging from 500:1 to 5,000:1 in various primary care service areas (PCSAs); the nearly 5000 PCSAs with a shortage have a deficit of over 54,000 PCPs, which is equal to the “surplus” in the 1,600 or so PCSAs who have higher ratios. And, of course, those underserved PCSAs comprise the vast majority of the US geographic area (see figure).

Phillips and colleagues estimate that we will need an additional 50,000-60,000 primary care physicians by 2025. The largest cause of the growth is, of course, the projected growth in the US population, but it is augmented by the aging of that population (older people require more health care services) and, significantly, the increase in the number of insured-and-thus-likely-to-access-health-care created by the new coverage provisions in the Affordable Care Act (ACA). This portion of the increase is smaller, but unlike the gradual growth resulting from the other two causes, will “hit” all at once in 2014, and our primary care workforce is in no way prepared to meet it. This lesson was emphasized by the experience that Massachusetts had when it introduced near-universal coverage; in addition to adding more people to the “insured pool”, the group that is added has pent-up health care needs. Moreover, the currently uninsured are largely clustered in areas with the lowest current PCP:population ratios, so that what will happen when they gain insurance is that they will end up seeking primary care in the emergency room. While the Graham Center estimates a need for an additional 8,500-10,000 primary care doctors, given what Dr. Phillips calls our “voodoo” workforce policy -- which not only does not incent students to enter primary care or locate in rural and underserved areas, but in fact does quite the opposite -- the actual increase in the number of providers would need to be many times higher. Much recent work has demonstrated the decrease in student interest in primary care, and in particular the phenomenal decrease in the percent of internal medicine graduates entering primary care (as opposed to entering subspecialties or hospitalist practice), as documented by Garibaldi[1] and Hauer[2] among others (see A Quality Health System Needs More Primary Care Physicians, Dec 11, 2008). More recent data collected by the American College of Physicians (ACP – the internists’ group) from residents taking required examinations in 2009 indicate that only 21% of these residents are planning careers in general internal medicine (65% subspecialties, 10% hospitalist) and the actual results tend to show that these plans tend to skew even more to the latter two groups when decisions are actually made.

I have pointed to money, specifically the anticipated income related to student debt, as a major determinant of specialty choice, and Dr. Phillips makes this quite graphic by comparing the ratio of primary care and family physician incomes to more highly paid specialties over time. Using Diagnostic Radiology and Orthopedic Surgery as comparators, primary care incomes, which were about 60% in 1979, dropped to barely 35% in 2003, a trend that has not decreased since. Other graphs show that the % of graduate training (residency) positions filled by US medical graduates tracks linearly with specialty income, and that the growth in new residency positions has been almost entirely in those high-income specialties with drops in primary care positions. (This is not only because of student interest; it is also because many of these new positions are funded by hospitals. The same specialists – radiologists, cardiologists, orthopedists, anesthesiologists – that make big incomes for themselves also make big profits for the hospitals, so that hospitals are more interested in increasing their capacity to do these functions by having more trainees, residents and fellows, in these specialties.)

This creates a problem. The Graham Center data support much other research that has been cited in this blog by Starfield and others indicating that a health system that is based on primary care, with 40-50% PCPs, creates the greatest benefit in health and lowers cost. We have currently about 32% PCPs. With an interest in primary care among medical students now at about 22%, the problem is going to grow, not shrink. And, as I have often written, if we are interested in increasing primary care specialty choice, we are largely taking the wrong students into medical schools (e.g., Primary care specialty choice: student characteristics, July 12, 2010). Given that these characteristics are in large part negatively associated with family income, the changes in funding for medical schools are also troubling. Phillips cites an interview with the founding dean of the University of Missouri-Kansas City (UMKC) medical school, E. Grey Dimond MD, in the Kansas City Star (April 25, 2011). Dr. Dimond is asked how UMKC, as the “public” medical school with the least state funding of any in the US, survives, and he answers that they have increased tuition to become the highest tuition school in the country. This, of course, does not bode well for low-income students, urban or rural, becoming physicians: “Farm kids in Missouri from little towns that need doctors can’t pay what we have to have.” And, for those low (and middle, and even upper-middle) income students who graduate with debts often exceeding $250,000, those income differences among specialties loom very large – and this does not bode well for primary care.

Phillips provides evidence that Medicare costs and avoidable hospitalizations and hospital readmissions drop dramatically when there are higher primary care ratios (ratios of 1 FP+NP+PA:1500-2000 people, or 1:1000 if all PCPs considered[3]). He cites a large number of studies demonstrating essentially the same thing.

Is there a bright side? Are there solutions? Well, the contributions of primary care are now being widely acknowledged, and there are lots of calls for increasing primary care physicians. The ACA bill provides some increased funding for primary care (about a 10% increase under Medicare) and major funding increases for the National Health Service Corps (NHSC), which pays for medical education by (some) scholarships or (mostly) loan repayment for physicians who enter primary care (and sometimes general surgery) and practice in an underserved area for a period of years. Unfortunately, these are not sufficient; a 10% increase sounds like a lot, but if it brings the primary care doctor’s income from 33% to 37% of that of a specialist (and this would be if the whole practice were Medicare), it is not going to do the trick. The loan repayment from NHSC is good, but it rarely covers the whole bill.

What would work? Medicare, taking the lead among all payers, needs to increase primary care physicians’ income dramatically. The Council on Graduate Medical Education (COGME) estimates in its very impressive 20th Report, Advancing Primary Care, that a family physician must be able to anticipate earning 70% of what a subspecialist makes if the goal of having a 40% primary care workforce in 20 years is to happen., the level at which income expectations tend to wash out of the decision on specialty choice. The federal and state governments should learn from successful models and repay all of the loans of medical school graduates who enter primary care over 8-10 years (enough time to ensure they are actually practicing primary care) and do it twice as fast for those who practice in an underserved setting.

This is what it will take to bend the curve of specialty choice, and, as a result, to bend the cost curve of providing health care.

[1] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12
[2] Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64
[3] The benefit on cost of hospitalization, avoidable hospitalizations, and readmissions is more difficult to assess for general internists than for family physicians; this would be unsurprising given that their training in almost all in the hospital rather than in the ambulatory setting.

Monday, May 23, 2011

Family Medicine in the Era of Health Reform - 3

In the last post in this series taken from the 21st G. Gayle Stephens lecture (Family Medicine in the era of health reform - 2, May 11, 2011), I discussed medical student interest in entering family medicine, and in particular a medical student named Kate Dewar featured in a NY Times article (More Physicians Say No to Endless Workdays). Her father and grandfather are primary care physicians but she is entering emergency medicine residency. In this final post, I continue the discussion, looking at changes in primary care practice and its implications for health and health care in the US.
The entire talk, "Family Medicine in the Era of Health Reform", is available at, in both GoogleDocs (for Chrome or Firefox) and Word (for IE) formats.

Of course, there are changes to primary care practice, but in my opinion, they are not all good. According the NY Times article, for Kate’s father, William Dewar III, “…the burden of trying to be all things to all of his patients became unmanageable. In 2006, after Wayne Memorial Hospital hired hospitalists — doctors who specialize in taking care of hospitalized patients — Dr. Dewar finally gave up hospital rounds. For his hospitalized patients, the change meant putting their trust in a doctor who knew them less intimately but was more available and more adept at hospital care. ‘My patients are getting better care now in the hospital,’ Dr. Dewar said. And the change saved him hours of work each week. ‘It meant getting off the hamster wheel,’ he said.”

Maybe they are getting better care, or maybe he just hopes that they are. And better in what way? It may be that hospitalists, who I call the “4-day ED docs”, are great at technical management but not so good (because of their role; I am not impugning their skill sets) at continuity. When your patient has a cold, or needs a BP check, they may be happy to see your partner, or even go to an urgent care center. But when they are sick enough to need to be in the hospital, when they need someone who knows them, they are not getting it. Yes, maybe they are getting someone who can balance their electrolytes, or operate on them in a skilful manner. Maybe, especially if they are lucky enough to be admitted on a Monday and not a Thursday they will even have a consistent management plan from their hospitalist (if not, perhaps, their nocturnist!) But where is the doctor who knows about them?

The surgeon may operate on your cancer, the oncologist and radiation oncologist may prescribe their treatments, the nephrologist may come in to manage the renal failure from the chemotherapy – but you still need the doctor who knows you. This is not a “social rounds” visit; this is caring for the patient, managing the various specialists. My sister was admitted to a hospitalist service in California some years ago (she is OK now) and after a few days the second (or maybe third) hospitalist told her that she looked a lot better. He’d known her for two days. My other sister, visiting from out of town, said “She may look better to you but she is NOTHING like she was last week! She is in no way back to normal!” Good for sisters who come in from out of town, but what if you don’t have one?

We need more primary care doctors, more family physicians, more doctors who can provide continuity for the health-related portions of our journeys through life. But when we get these doctors, what is their life like? I recently met a very smart and committed young family doctor who works at a Federally Qualified Health Center (FQHC) in one of our more “desirable” cities. Even though she doesn’t deliver babies, and doesn’t take care of patients in the hospital, she still felt she was on a hamster wheel, often giving less-than-the-best-care-she-knew-she-could-give to the patients hustled through so that the FQHC could “make its numbers”. She wanted to know what could be done to support the family doctors who are out there working as hard as they can for relatively little money and in danger of burning out. Apparently, just expanding FQHCs to see more patients is not going to do it.

There has to be a solution that provides the benefits of a primary-care based health system to our people without balancing it on the backs of the primary care doctors, who don’t have enough time with their families and don’t have enough time with their patients. Who have to give up even the satisfactions that come from the happy moments of primary care, like delivering babies, and the times when your patients, admitted to the hospital, really need you. And doing it for a salary that, even if it far exceeds that of the average American, is a fraction of what your medical school classmates are getting for working less hard, and makes it difficult to pay off your loans.

If the US is going to benefit from a primary-care-based health system, it is going to have to address the input and process variables of medical education, that is who is admitted and what their experiences are in medical school, the things that lead them to choose specialties, and also the output variables, what the practice life experience is, and make sure that it is tolerable and sustainable.

We know what the characteristics of medical school applicants who are more likely to enter primary care and rural practice are; dozens of pilot programs have demonstrated them. They are students who are from rural areas, from under-represented minority groups; students who are older, and students who are from lower-income families. They also, on the whole, have lower Medical College Admissions Test (MCAT) scores. For those students who do come from higher-income, white, suburban families (who have always been and continue to be the vast majority of those admitted to medical school), the characteristics are a demonstrated history of service (e.g., Peace Corps, VISTA, Teach for America, carrying the rape crisis pager in college, volunteering in a free clinic).

And we are not, not in large enough numbers, not high enough percents. Demonstration projects are of little use if that is where they stay, if we don’t learn the lessons and implement them for the vast majority of medical school admissions.

The 2010 “Top 25” Family Medicine schools as rated (entirely by survey reputation) by US News vary widely in their percentage and number of students entering primary care. Over the 5 year period 2004-08, they ranged from the University of Minnesota with an average of 17.36% of their class, or 37.8 students, entering FM, to Duke with an average of 2.8% or 3.45 students. Of course, US News’ top 25 are not the same as the actual top 25 in students entering family medicine; my school, the University of Kansas (which is not in the US News’ top 25) averaged 20.3%, or 33.4 students, over that period. Since the national average over that period was 8.71%, or 10.8 students, apparently you can be a top FM school, at least according to US News’, and be well below the national average of students entering FM.

More important, even the actual top schools in producing family doctors have pretty low percentages, ranging from 13% to 20%. We are never going to get to the 40-50% primary care work force we need by producing less than 20% family doctors in the best schools. The worst schools – like Duke, Johns Hopkins and Harvard should be at 20%; KU and Minnesota should be much higher.

And when students are in medical school, we need to be sure both that there is adequate exposure to longitudinal continuity and interdisciplinary and inter-professional primary care, and that those experiences are positive. While I have said that Family Physicians need to be involved in caring for their patients in the hospital, students should not be able to go through medical school, as they do now, thinking that the hospital is the main venue for real health care.

And when those students we have carefully selected and nurtured graduate, and do enter primary care, they need to be able to expect to have reasonable lives. It seems obvious, but a lot of this is about money. Primary care doctors need to make more money, if not in absolute dollars, at least in terms of the percent of subspecialist income. Income does not have to be equal; work from the Robert Graham Center demonstrates that the effect of debt income disappears when primary care doctors make 70% of what specialists make. Medical school debt should be gradually forgiven for students who enter primary care, and forgiven at a much faster rate if they work in a rural area or HPSA.
Where will this money come from? There is no reason to expect that, in a country that already spends twice as much per capita as most other industrialized countries, all of which have better health outcomes, that there will be more money coming into the system. It is going to have to come from other parts of the health sector; the parts being collected now by hospitals and other specialists, in particular. It will also have to come from the profit being taken out of the system by those hospitals and even more by for-profit insurance companies and drug companies. There can be no room for so many “health dollars” going to investor profits, nor can there be perverse financial incentives that make it more desirable to treat sick people than to keep them from getting that sick. There must be a comprehensive approach, for otherwise there will always be “gaming of the system”, and this is where the big failing of ACA is.

We need continue to need specialists, so it is good that Kate Dewar gets her satisfaction from emergency medicine, or that others like to put people to sleep, read slides or x-rays, perform surgery, or see the same diagnoses over and over again in subspecialty practices. But we need a lot more primary care doctors – and nurse practitioners – more family doctors.

We need policies at every level, at those of the medical school and the LCME, and the ACGME, and the state and federal governments, that encourage us to take students who are more likely to enter primary care, to nurture them through their training so that they actually do enter primary care, and to provide a practice setting in which they can feel satisfied that they are providing excellent, patient centered – and population-conscious – care without giving up all of their personal lives.

Tuesday, May 17, 2011

Insurance company profits up and patient care down

The third post in the series "Family medicine in the era of health reform" will appear at a later date. I  wanted to cover another topical issue.

Almost a year after the passage of the Affordable Care Act (ACA), amidst the dire predictions from the right about everything from death panels to socialism and their bloviating about overturning it, it turns out that the fears of the “left” are more accurate; that is, that it is insurance companies, not the American people, who are receiving the greatest benefits. There have indeed been benefits to consumers; notably the ability of young people to stay on their parents’ insurance until 26 and the elimination of restrictions on pre-existing conditions, and there will be more later on as 2014 rolls around. But the biggest impact of the bill so far has been inflating the coffers of health insurers.

The lead article in the New York Times, May 14, 2011, by Reed Abelson, is Health Insurers Making Record Profits as Many Postpone Care. In his wonderful daily commentary on health news, Quote of the Day, Dr. Don McCanne simply observes “The headline says it all.” That’s the gist of it, but it does deserve a little more discussion. For one thing, the health insurance companies, despite record profits over the last two years, are continuing to raise their premiums very significantly, justifying this by saying that they expect that, as the economy improves, people who have been delaying getting health care will begin to do so and create a great demand.

“Yet the companies continue to press for higher premiums, even though their reserve coffers are flush with profits and shareholders have been rewarded with new dividends. Many defend proposed double-digit increases in the rates they charge, citing a need for protection against any sudden uptick in demand once people have more money to spend on their health, as well as the rising price of care.”

Excuse me? This is a justification for raising rates now? That people, insured people, find the co-pays and deductibles currently in place to be so high that they are denying themselves needed care, so maybe later they’ll want to get it, so then it will finally cost the insurers money, so let’s pre-emptively raise premiums to cover it? Meanwhile, what it actually does is to ensure that even fewer people access care because the higher rates mean that they opt for policies with even greater co-pays and deductibles or even drop their insurance altogether.

The article quotes a number people, including physicians, describing how they or their patients have gone without or put off obtaining health care.
“’I am noticing my patients with insurance are more interested in costs,’ said Dr. Jim King, a family practice physician in rural Tennessee. ‘Gas prices are going up, food prices are going up. They are deciding to put some of their health care off.’ A patient might decide not to drive the 50 miles necessary to see a specialist because of the cost of gas...”
While the insurance companies are using the opportunity to stash away even more money for the flood that may, or may not, come: the Times quotes an industry analyst as saying about demand for health care services “The big question is whether it is going to stay weak or bounce back…Nobody knows.” They are raising their rates by double digits (for example, an Oregon Blue Cross/Blue Shield raised them by 22%), while having big profits (“…big insurance companies have reported first-quarter earnings that beat analysts expectations by an average of 30 percent.”)

Some of the reports suggest that people seem less interested in getting medically unnecessary services which they wanted when someone else was paying; according to Dr. King ”Fewer [people] are asking for an MRI as soon as they have a bad headache. “People are realizing that this is my money, even if I’m not writing a check.”  But others, such as the woman who has been putting off paying $350 for dental crowns she has needed for a year, are avoiding needed care. The effect on the health of the consumer may not be all bad; a doctor says more patients are “…asking for the generic alternatives to brand-name medicines, because of hefty co-payments. ‘Now, all of a sudden, they want the generic, when for years, they said they couldn’t take it.’” Let me be clear: in general, choosing generic drugs is a good thing; it is very uncommon that a patient is intolerant or allergic to a generic medication, or that it works less effectively than a brand-name one. Why, then, have this doctor’s patients heretofore been asking for them and saying that they “couldn’t take” the generics?

If you guessed “drug company advertising”, congratulations! It may seem obvious but it is also true; direct-to-consumer advertising, particularly on television, has major impact in creating demand from people on their doctors. The advertising is, of course, all for brand name drugs that are currently under patent and not available generically. Like other advertising for brand-name products it creates the (usually incorrect) impression that, somehow, this drug is better than the “no-name” drug. Why should this be surprise when it is clear that people prefer brand names in clothes, food, and other consumer items even when there is no demonstrated quality difference? [Amazingly (to me), people  -- even people over 14 years old! --pay good money to walk around with a designer’s name scrawled across their T-shirt and believe that this has cachet!]

The simple goal of drug manufacturers is to get people to switch to their drug when it comes out, develop brand loyalty when it is under patent, and stay with the brand even when generic competitors come out. The actual best thing for people’s health is to rarely adopt a new drug that “seems like it might be” better (unless all the old drugs are not working or have serious side effects or allergies), but rather wait until there is convincing evidence, usually after several years of use, that it is both more effective and has fewer dangerous side effects than the old drug it was replacing, especially if it is not cheaper. So, to the extent that higher co-pays and deductibles might counteract the impact of drug-company advertising, it can have a positive impact, and fulfills the expectations of many health care economists.

But it is not, after all, a very good way to do it. Raising health insurance premiums and co-pays and deductibles may make people more cautious with their health care dollar, but as indicated in this article, and shown years ago in the RAND Health Insurance Experiment (as cited in Freedom abroad, health at home: experiments in preventive health care, February 13, 2011; the study was published in the New England Journal of Medicine in 1983[1]; and it is summarized in an article by Joseph P. Newhouse, "Free for all?:  lessons from the RAND Health Insurance Experiment", RAND 1993), people are at least as likely to skimp on  necessary care and preventive care that may have a negative impact on their health, as well as be more likely to create high costs, in the future, as they are to forego elective or unnecessary care. They may not demand an MRI for a headache, but also may not want to pay for it when it is medically indicated. They may be more likely to ask for generic drugs, but may also skip filling the prescriptions altogether.

Dr. McCanne continued his brief comment by saying “Under the Affordable Car Act we're getting more of the same, except worse (higher costs, skimpier coverage). It doesn't have to be this way.” He is completely correct.  There is a better way to control costs, and to ensure quality health care. It is to make sure that everyone has coverage, such as through the single-payer plans recently introduced in the Senate by Bernie Sanders and the House by Jim McDermott, to have central pro-active control of costs by regulation of premiums and profit, using the power of bulk purchasing by federal agencies such as CMS to drive down drug prices, and to use the incredible power of an increased primary care workforce to increase quality and “bend the cost curve”. More on that in an upcoming blog.

[1] Brook RH, et al., “Does Free Care Improve Adults' Health? — Results from a Randomized Controlled Trial”, N Engl J Med 1983; 309:1426-1434

Wednesday, May 11, 2011

Family Medicine in the era of health reform - 2

This is the second of three parts presenting the content of the 21st G. Gayle Stephens lecture that I gave at the Primary Care Access Conference. It more specifically addresses the current status of family medicine, and in particular, family medicine training.

What about Family Medicine? There has been something of an uptick of interest in FM among medical students in recent years, which has been reflected in “better” matches: a larger number of US medical graduates (USMGs) entering family medicine residency training and fewer residency slots filled by IMGs; but these are small changes, nowhere near sufficient to meet the nation’s needs for primary care doctors.  In addition, we are not sure of the reason for this yet. We hope that it is a real increase in interest, but it may also be (and continue to be) a result of increases in medical class size and number of medical schools without a concomitant increase in residency positions, leaving more students who cannot match in their more desired specialties and thus “settle” for family medicine.

Common sense, and some recent data (especially regarding loan burdens), suggests that reimbursement is an major issue, and this is something I have addressed on several previous occasions (recently The challenge of expanded Medicaid and the dearth of primary care physicians, Feb 19, 2011). Although money (income and debt) was not found to be a major determinant of specialty choice in the “Arizona studies” several years ago;[1];, debt loads have increased since then, frequently exceeding $250,000 by the time of medical school graduation. More concerning, we are increasingly hearing reports of negative attitudes among medical students toward the real or perceived lifestyle of primary care, as well as persistence of the idea that primary care -- family medicine – is not as interesting or as challenging as practice in other specialties.

A recent article that appeared in the New York Times on Saturday, April 2, More Physicians Say No to Endless Workdays, illustrates many of these issues as it describes the decision of a young female student, Kate Dewar, to enter Emergency Medicine rather than the primary care practice of her father and grandfather. She is the mother of twins and although she says
“Look, I’m as committed to being a doctor as anyone. I went back to work six weeks after my boys were born. I love my job,” she adds “But I was in tears walking out of the house that first day. I’m the mother of twins, and I want to be there to feed them, play games with them or open presents with them on Christmas morning. Or at least I want the option to do those things without fearing I’ll be called back to the hospital.”

Yes, it is possible that her commitment is simply professed, not real; maybe in an objective sense she is not as committed to medicine as her father and grandfather. And if not, if she is more committed to her family, is that a bad thing? Her grandfather, Dr. William Dewar II, is quoted as saying “My son and I had deeper feelings for our patients than I think Kate will ever have… “ and her father, Dr. William Dewar III, adds “I’ve had three generations of [the owner of the cafĂ© in which they are being interviewed]’s family under my care. Kate will never have that.”

Yes, but she will fewer work hours. The article notes that “…emergency room and critical-care doctors work fewer hours than any other specialty, according to a 2008 report from the federal Department of Health and Human Services.” And she will not get paid less for working those fewer hours; actually she will be paid quite a bit more. Personally, I have seen little indicating that, overall, students are willing to get paid less in exchange for having more time with their families.

What about the other part? The ostensible lack of intellectual, or at least, adrenaline-infused, challenge? The “Marcus Welby” vs “ER” dynamic? Kate Dewar told the Times “…that treating chronic conditions like diabetes and high cholesterol — a huge part of her father’s daily life — was not that interesting. She likened primary care to the movie ‘Groundhog Day,’ in which the same boring problems recur endlessly. Needing constant stimulus — she e-mails while watching TV — she realized she could not practice the medicine of her forebears.”
Constant stimulus aside – everyone emails while watching TV (is there any other way?) --  is she correct in that primary care does not have enough intellectual stimulation? If we look at medical and surgical subspecialties, it is hard to make that argument. They all see a much narrower range of diagnoses than primary care physicians do. For most of them, their top 5 diagnoses account for 80% or more of their visits; for family medicine our top 20 diagnoses account for perhaps 30%. Indeed, this is in part why we enter FM. 

Is the Emergency Department really that different? There are certainly the big, exciting cases, but also a lot of routine. ED docs often complain that they have to do so much primary care – and they do it without gaining the satisfaction that doctors like the older Dewars get from seeing people get better over time. In addition to the primary care, there are the overdoses, and accidents, and the “frequent flyers” that characterize much of ED work. Yes, ED physicians can resuscitate people from the overdose – but they don’t treat the depression or the domestic violence that frequently was the cause. Yes, they stabilize fractures and abdominal trauma so that patients can be admitted to the surgeons (unlike on television’s “ER” where they seem to do major surgery in the ED, not to mention pushing babies back into the uterus of eclamptic women for whom there is “no room” on the labor floor – this would never happen!) – but they can do nothing to prevent the next one walking in. Yes, they admit the person from the nursing home with decompensated congestive heart failure and get them into the ICU – but if the patient lives until they can be discharged, they will be back again soon. Yes, they complain about the lack of primary care services available that make people come in with relatively minor illnesses, or even worse, with advanced stage illnesses that could  have been ameliorated by primary care – but they don’t want to be the ones to do it.

Kate Dewar says “I like it when people get better, but I’d rather it happen right in front of my eyes and not years later… [I] like to fix stuff and then move on.” At its face value this can be seen as an immature statement; while such attitudes can and do persist for an entire career for some people, they become less pervasive as doctors learn both the satisfaction that her father and grandfather demonstrate that comes from following patients over years, as well as the frustration that comes from “fixing” the same stuff over and over again. Of course, if she is an adrenalin junkie, maybe the ED will be a good place for her.

But the adrenalin rush can wear off, or be eroded. I worked for many years at Cook County Hospital, where there is a Department of Trauma. It recruits many skilled young adrenalin-junkies who want to be like Hawkeye Pierce on “M*A*S*H”, seeing people get better right in front of their eyes. Except not always. Often they don’t get better, they die. And then you have to tell their family. Another auto accident, another gang shooting, another alcohol-enhanced beating.  And then you have to tell their family. And then again, and again. And then, after a while, you get tired of it, which is why so many trauma surgeons spend so much of their time out in the community, talking to people, trying to prevent themselves from having more business. They want to decrease, not increase, their business. 

Or maybe Kate Dewar just doesn’t have the interest in working with people over time and developing the relationships with patients that her father and grandfather did, and that all the stories they tell about their great longitudinal relationships with patients are, for her, dissolved in a memory of beepers going off as her dad sat down to dinner, or on Saturday and Sunday morning. Or maybe she is just selfish. I don’t know about her, but I think that all of these possibilities can apply to many different students.

What remains true, however, is that we  -- this nation – needs to change our health care business model, to keep people from getting so sick that they need emergency rooms and high-tech procedures. In Denmark, for example, the number of hospitals dropped from 190 in 1980 to 52 in 2004[2];, not because some have driven their competitors out of business but because they are no longer needed.

Wouldn’t that be a victory?

[1] Senf J, Campos-Outcalt D, Kutob R, “Factors Related to the Choice of Family Medicine: A Reassessment and Literature Review”, J American Bd of Family Practice, 2003, 16:502-12.

[2]Kristensen T, et al., Economies of scale and optimal size of hospitals: Empirical results for Danish public hospitals”, Health Economics papers 2008:11, University of Southern Denmark

Thursday, May 5, 2011

Family Medicine in the era of health reform

At the recent Primary Care Access Conference in San Francisco, I was given the opportunity to present the 21st G. Gayle Stephens lecture. It was a real honor, because it is named for one of the giants of family medicine, and one of the great thinkers on health and medicine of the last half century, in any field. Dr. Stephens was the first director of one of the nation’s first family medicine residencies, at Wesley Hospital in Wichita, KS, and later Chair of the Family Medicine department at the University of Alabama. He was an early and long-time member of the American Board of Family Practice (later Family Medicine) and the author of several of the most seminal articles and books in the field, including “The Intellectual Basis of Family Practice” and “Family Medicine as Counterculture”.  Both of these pieces, along with many others, are discussed in the outstanding “festschrift;[1; put together by another giant of the discipline, John Geyman, in the January 2011 issue of Family Medicine.

Dr. Geyman says of Dr. Stephens that “He has been, and remains, by far the most original, thoughtful, and elo­quent voice in our field and among the few who best represents the mor­al conscience of the entire medical profession.” I have been privileged to have met, corresponded with, and even to a limited extent collaborated with both Dr. Stephens and Dr. Geyman. I can only hope that my talk was worthy of being associated with Dr. Stephens’ name. In this piece, I  would like to discuss a few of the points I made in that talk related to health care reform, or the Affordable Care Act (ACA); in a later blog I will discuss this in terms of the impact on primary care and family medicine.

Unquestionably the health care reform act, or ACA, is the biggest change in health coverage since Medicare and Medicaid in 1965. It remains deeply flawed, but is nonetheless the touchstone of the opposition to the current administration, as President Obama’s opponents apparently see in it everything that we don’t! The fact is that, rather than bringing us a health system in which everyone is covered, like Canada, or the UK, or Germany, or Switzerland, or Taiwan, it is in large part a big bailout of health insurance companies. And the price that for this – the requirement that everyone have to buy health insurance, the “individual mandate”, is what we hear being attacked, not the insurance companies that demanded it as the price for supporting ACA.

There are some of the parts of ACA that are rather non-controversial (except to the extent that they might not be funded as part of the “don’t fund anything” movement), and are good for family medicine, in the sense that they are good for the health of the American people. These include the increased funding for Federally-Qualified Health Centers (FQHCs), the creation of a panel to review the evidence of effectiveness, if it is left in, and the Primary Care/Health Extension services (which thus far have received no appropriation), among others.

One important component of ACA is the creation of “Accountable Care Organizations”, or ACOs, initially for Medicare patients. They are an effort to promote health by having health providers financially responsible for the health of their patients, that is, to have ambulatory care facilities and doctors, hospitals, nursing homes, and community care facilities coordinate their efforts to prevent illness, treat effectively, and have people cared for in the most appropriate setting, rather than perverse “gaming of the system”, where a failure of ambulatory health care can be a “win” for a hospital when a patient is admitted (as long as they don’t stay too long, or get re-admitted too soon). This kind of structure works well in HMOs, such as Kaiser, or other integrated health systems, but there are likely to be flaws in its implementation; for example, Center for Medicare and Medicaid Services (CMS) administrator Dr. Donald Berwick recently published guidelines for Medicare ACOs in the New England Journal of Medicine, Launching Accountable Care Organizations — The Proposed Rule for the Medicare Shared Savings Program.  He says that the ACOs will be “Held to rigorous quality standards (see table). Proposed Measures for ACO Quality-Performance Standards.), ACOs will be expected to be proactive in their orientation and to regularly reach out to patients to help them meet their needs for preventive and chronic health care.”

However, Berwick immediately adds that “Patients who seek care at their ACO will know that their physicians are part of that ACO, but as beneficiaries of fee-for-service Medicare, they will continue to be free to seek care from any Medicare provider they wish. They will not be locked into seeing only particular health care providers.” This sounds relatively benign, and certainly politically wise, but could completely undercut the effectiveness of the program. The reason that Kaiser and other HMOs are effective in managing care that delivers high quality at low cost is because their patients are restricted to where they can seek services; if a Medicare patient who is part of an ACO does not like that they have been “denied” any form of care by their doctor or hospital, no matter how appropriately, can now go “outside the system” to another doctor, hospital, emergency room or pharmacy-based urgent care clinic, all efforts at cost control are at risk. This is, of course, the conundrum: control of costs requires some degree of restriction of unlimited options. It is quite parallel, in fact, to the “individual mandate” that the insurance companies demand, and in this sense they are correct. It will not work to require insurance companies to insure everyone if everyone is not required to have insurance, because then only those who need care will demand coverage, risk goes way up, and so would premiums.

Some politicians and pundits have compared ACOs to the managed care era of the 1990s, and supporters worry it will receive the same backlash from the public that occurred then. I believe that in that period it was not managed care that was at fault but two major characteristics that happened in conjunction with it. The most important was that the entire operation was taken over by for-profit companies, largely insurance companies, that saw benefit to their bottom line by restricting care. The efficiencies of consumer cooperative HMOs had benefited their members; these new entities denied care to benefit their stockholders. It was the corporate for-profit control, not the management of care, that led to consumer dissatisfaction with restrictions on access to care.
The second big problem is related to one that I have discussed before (Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009), the fact that most people are not sick. In an effort to control costs, everyone was made to jump through hoops, such as gatekeepers and prior authorization, which made them angry but did not do much for the cost, since most people do not use much medical care. Indeed, for at least half the population, you could let them do whatever they want, and they wouldn’t use any significant number of health care dollars. To illustrate this, I am reproducing the graphs from the previous blog.

While there are some things we can do to reduce the risk of unexpected crises –cancer, multiple trauma from car accidents, infants in NICUs – and control the costs of caring for those who have them, the most obvious benefit will be achieved by pre-emptively working with people whose chronic diseases have gotten so bad that they are frequently admitted, often to Intensive Care Units. These are the people who should be targeted for intensive intervention, not only medical but in terms of the social determinants of health, such as in the programs highlighted by Atul Gawande in his February 2011 New Yorker piece, “The Hot Spotters”. Needless to say, such interventions are being funded on a shoestring, while the high-tech interventions get all the money.

 It doesn’t have to be this way. We could have a rational, cost-effective health care system if we start with coverage for all through a single-payer mechanism. We might be able to back into quality despite not having one, but it will be much harder.
<!--[if !supportFootnotes]-->[1]<!--[endif]--> Festschrift: “A volume of learned articles or essays by colleagues and admirers, serving as a tribute or memorial especially to a scholar

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