Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people

 I -- and many others -- have written (frequently and recently) about the abuses of for-profit companies, and especially private equity companies, and “non-profits” that act like for-profits in health care (Private equity, private profit, Medicare and your health: They are incompatible, May 11, 2023; Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!, Jan 20, 2023; "Private Equity": Profiteers in nursing homes, Medicare Advantage, DCEs, and all of healthcare, Sept 16, 2022). But despite our efforts, it doesn’t get any better. Indeed it gets worse.

Drs. David Himmelstein, Steffie Woolhandler, Adam Gaffney, Don McCanne, and John Geyman, have been leaders in the campaign for a national health insurance plan (e.g., Medicare for All), published an article 18 months ago in ‘The Nation’ (March 31, 2022) titled ‘Medicare for All is Not Enough’. They go through the ways in which the ownership of our health system has changed, particularly over the last decade, to focus on profit for the private owners rather than “health care”. That is to say, while a single-payer Medicare for All program would be a great thing and would limit the negative impact that for-profit insurance companies wreak on our collective health – which is considerable – as long as for-profit companies continue to own, and to increase their share of, our actual health delivery systems (hospitals, nursing homes, pharmacies, and physician practices) there will be terrible consequences, with those single-payer dollars flooding into investors’ pockets rather than patient care.

Insurance companies like United Health and giant pharmacy firms like CVS own large portions of our practice and health delivery sector. And the role of private equity companies and investors, with their “buy ‘em and burn ‘em” approach to acquisition and profit, in taking over our delivery system is at least as terrifying. As the authors state:

At least UnitedHealth and CVS plan to stay in business for the foreseeable future, and may be constrained by the worry that substandard care will damage their reputation. Private equity companies face no such constraints. They promise investors quick profits, and often sell off the businesses they’ve bought within five years, often after stripping their assets and loading them with debts that hobble future operations.

On top of who will own our care provision, there also is the issue of who will provide the care. Most developed countries, with more rational health delivery systems, rely on primary care physicians and other clinicians far more than the US does. In those other countries primary care is at least 30-40% of the physician workforce, while here it is closer to 20% and dropping, an issue I have written about often (see, for example, What is the problem with Primary Care? The US health system!, March 22, 2022).  Primary care clinicians – family physicians, pediatricians, and general internists, and the NPs and PAs who work with them – can provide not only cost-effective care but care that is comprehensive, continuous, and reassuring to people and families because they know the person who is providing it and have a relationship with them. And the cost-effectiveness is not (only) about the fact that they earn less money (see below) but because they are in a position, as a result of taking care of the “whole person” and having a long term relationship, to more wisely utilize resources when necessary. Nonetheless, there is a definite shortage of primary care clinicians, as anyone who has tried to find one recently, because they moved, or their physicians retired or had their practice bought out by a large company like Optum (a subsidiary of United Health Care, which has become UHC’s major profit center as documented by former insurance executive Wendell Potter in his “Health Care Un-covered” substack) or, sometimes in response, went into a “concierge” or “boutique” practice, can testify. Elisabeth Rosenthal, editor of Kaiser Health News, documents this in a recent piece in the Washington Post, “The Shrinking Number of Primary Care Physicians is Reaching a Tipping Point”. She notes that “fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients.” And she makes the important point that

One explanation for the disappearing primary-care doctor is financial. The payment structure in the U.S. health system has long rewarded surgeries and procedures while shortchanging the diagnostic, prescriptive and preventive work that is the province of primary care.

Don’t forget that one. Rosenthal discusses the terrible experience of colleague Bob Morrow, MD, who, under financial pressure, finally had to sell his decades-old practice, and then, watching how the new owner ran it (suffice it to say, not in the best interests of the patients), leave medicine. Morrow is not a depressed person, but reading about what has happened to him and thousand of other primary care doctors is enough to make you depressed.

In a data-driven “Report Card” on primary care in the US, the Milbank Memorial Fund ranks it poorly on all front, although not on the quality of the physicians:

This first national primary care scorecard finds a chronic lack of adequate support for the implementation of high-quality primary care in the United States across all measures, although performance varies across states. The scorecard finds:

1.      Financing: The United States is systemically underinvesting in primary care.

2.      Workforce: The primary care physician workforce is shrinking and gaps in access to care appear to be growing.

3.      Access: The percentage of adults reporting they do not have a usual source of care is increasing.

4.      Training: Too few physicians are being trained in community settings, where most primary care takes place.

5.      Research: There is almost no federal funding available for primary care research.

The  report card, created for Milbank by the Robert Graham Center (the policy arm of the American Academy of Family Physicians, AAFP), not only identifies these deficits, but also the importance of solving them for the health of the American people. 100,000,000 people without a primary care doctor, only able to see a physician (if they can see any physician) who has a narrowly focused, disease-based practice is a real problem. We need those specialists for when we are diagnosed with a particular condition that requires their expertise, but they are often not knowledgeable about conditions outside it. Moreover, the primary care clinician does not only care for many conditions; much more important is that they care for the person who has those conditions.

The report also endorses the conclusions from the National Academy of Science, Engineering, and Medicine (NASEM) from 2021, recommending that the US:

1. Pay for primary care teams to care for people, not doctors to deliver services.
2. Ensure that high-quality primary care is available to every individual and family in every community.
3. Train primary care teams where people live and work.
4. Design information technology that serves the patient, family, and interprofessional care team.
5. Ensure that high-quality primary care is implemented in the United States.

Finally, for the moment, an effort is actually being made in Congress to try to increase the number of primary care clinicians.  In an uncommon bipartisan effort, the bill is cosponsored by Bernie Sanders (I, VT), chair of the Senate HELP Committee and Roger Marshall, MD, an OB/GYN and conservative Republican from Kansas, as reported by Jake Johnson in Common Dreams, Sept 14, 2023. It’s a good thing to have bipartisan support, but it is, sadly, unlikely to have a major effect on increasing the primary care physician supply. Funding in the bill – about $6 billion -- goes mainly to Community Health Centers (CHCs), especially Federally-Qualified Health Centers (FQHCs). These centers can be, and usually are, good. They provide care to lower-income people and communities where access to other clinicians is difficult. Republicans like them because they are not actually “government” programs, but responsible only to their boards of directors. But, while they often rely heavily on primary care, and expanding them will increase the number of jobs for primary care clinicians, it does nothing to increase the supply of those clinicians, to convince medical students to enter family medicine, pediatrics, and general internal medicine instead of much higher-paying subspecialties.

I mention money, the Milbank report mentions money. It is a lot about money. It is increasingly difficult to convince students to enter fields where their income is likely to be a fraction of that of subspecialists (even if much better than that of most Americans), especially in the context of huge educational debt (frequently over $250K), and the lack of respect given by the medical profession and often the society at large to primary care. And, not at all to be minimized, the takeover of so many practices by for-profit corporations and private equity, with situations like Dr. Morrow’s becoming the norm rather than the exception. Some subspecialties make 2-3 or more times that of primary care doctors, which makes it increasingly difficult for students to decide to enter primary care. And while some of these subspecialties have grueling work hours (e.g., general surgery) others have much more circumscribed work hours, often shift work and little call.

There IS certainly something the federal government could do. The Center for Medicare and Medicaid Services (CMS) sets the relative reimbursement for physician services (office visits, procedures, etc.) and virtually all private insurance companies reimburse based on multiples of the Medicare rate (traditionally more, but now often less). So all CMS has to do is to revise its fee schedule, increasing the relative value of primary care visits relative to procedures. Of course, there will be great opposition from other specialists; indeed the “RUC”, a non-government committee that advises CMS on this ratio is completely dominated by subspecialists (Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013). CMS is not required to follow the recommendations of the RUC although it usually does; CMS could ignore or adjust what the RUC recommends, or reconstitute the membership of the RUC to have more primary care doctors. Primary care physicians do not need to make as much as the highest-paid subspecialists (indeed neither do those subspecialists!) but the difference needs to be decreased. Studies have indicated that if primary care doctors earned 70% of what subspecialists do, income would no longer be a significant factor in specialty choice.

Addressing this income gap is critical for increasing the number of primary care clinicians. Then there is a lot else to do, like getting for-profit corporations and private equity out of healthcare altogether.

 

For a “humorous” depiction of the takeover of primary care by for-profit companies like Optum, check out this short piece by the brilliant Dr. Glaucomflecken: https://twitter.com/i/status/1706339952857149895

Medical schools are no place to train physicians

Doctors have to go to medical school. That makes sense. They have to learn their craft, master skills, and gain an enormous amount of knowledge. They also, and this is at least as important, need to learn how to think and how to solve problems. And they need to learn how to be life-long learners because new knowledge is constantly being discovered, and old truths are being debunked. Therefore, they must learn to un-learn, and not to stay attached to what they once knew to be true but no longer is. They also need, in the face of drinking from this fire-hose of new information and new skills, to retain their core humanity and their caring, the reasons that (hopefully) most of them went into medicine.

Medical students struggle to acculturate to the profession, to learn the new language replete with eponyms, abbreviations, and long abstruse names for diseases (many are from Latin, and while they are impressive and complicated, they are also sometimes trite in translation, e.g., “itchy red rash”). They have to learn to speak “medical” as a way to be accepted into the guild by their seniors, but must be careful that it does not block their ability to communicate with their patients; they also need to continue to speak English (or whatever the language is that their patients speak). “Medical” may also offer a convenient way of obscuring and temporizing and avoiding difficult conversations (“the biopsy indicates a malignant neoplasm” instead of “you have cancer”).  But there needs to be a place for them to learn.

So what is wrong with the places that we are teaching them now? Most often, allopathic (i.e., “MD”) medical schools are part of an “academic health center” (AHC), combined with a teaching hospital. They have large biomedical research enterprises, with many PhD faculty who are, if they are good and lucky, are externally funded by the National Institutes of Health (NIH). Some or many of them spend some of their time teaching the “basic science” material (biochemistry, anatomy, physiology, microbiology, pharmacology, pathology) that medical students need to learn. By “need to learn” we usually mean “what we have always taught them” or “what they need to pass the national examination (USMLE Step 1) that covers that material”. This history goes back 100 years, to the Flexner Report of 1910. Contracted by the AMA, educator Abraham Flexner evaluated the multitude of medical schools, recommended closing many which were little more than apprenticeship programs without a scientific basis, and recommended that medical schools be based upon the model of Johns Hopkins: part of a university (from the German tradition), grounded in science, and based in a core curriculum of the sciences. This has been the model ever since.

However, 100 years later, these medical schools and the AHCs of which they are a part have grown to enormous size, concentrating huge basic research facilities (Johns Hopkins alone receives over $300 million a year in NIH grants) and tertiary and quarternary medical services – high tech, high complexity  treatment for rare diseases or complex manifestations of more common ones. They have often lost their focus on the health of the actual community of which they are a part. This was a reason for two rounds of creating “community-based” medical schools, which use non-university, or “community”, hospitals: the first in the 1970s and the second in the 2000s. Some of these schools have maintained a focus on community health, to a greater or lesser degree, but many have largely abandoned those missions as they have sought to replicate the Hopkins model and become major research centers. The move of many schools away from community was the impetus for the “Beyond Flexner” conference held in Tulsa in 2012 (see Beyond Flexner: Taking the Social Mission of Medical Schools to the next level, June 16, 2012) and for a number of research studies focused on the “social mission” of medical schools.

The fact is that most doctors who graduate from medical school will not practice in a tertiary AHC, but rather in the community, although the other fact is that a disproportionate number of them will choose specialties that are of little or no use in many communities that need doctors. They will, if they can (i.e., if their grades are high enough) often choose subspecialties that can only be practiced in the high-tech setting of the AHC or the other relatively small number of very large metropolitan hospitals, often with large residency training programs. As they look around at the institution in which they are being educated, they see an enormously skewed mix of specialties. For example, 10% of doctors may be anesthesiologists and there well may be more cardiologists than primary care physicians. While this is not the mix in world of practice, and still less the mix that we need to have for an effectively functioning health system, it is the world in which they are being trained.

The extremely atypical mix of medical specialties in the AHC is not “wrong”; it reflects the atypical mix of patients who are hospitalized there. It is time for another look at the studies that have been done on the “ecology of medical care”, first by Kerr White in 1961 and replicated by the Robert Graham Center of the American Academy of Family Physicians in 2003 (see The role of Primary Care in improving health: In the US and around the world, October 13, 2013), and represented by the graphic reproduced here. The biggest box (1000) is a community of adults at risk, the second biggest (800) is those who have symptoms in a given month, and the tiny one, representing less than 0.1%,  is those hospitalized at an academic teaching hospital.  Thus, the population that students mostly learn on is atypical, heaving skewed to the uncommon; it is not representative of even all hospitalized people, not to mention the non-hospitalized ill (and still less the healthy-but-needing-preventive care) in the community.

Another aspect of educating students in the AHC is that much of the medical curriculum is determined by those non-physician scientists who are primarily researchers. They not only teach medical students, they (or their colleagues at other institutions) write the questions for USMLE Step 1. They are often working at the cutting edge of scientific discovery, but the knowledge that medical students need in their education is much more basic, much more about understanding the scientific method, and what constitutes valid evidence. There is relatively little need, at this stage, for students to learn about the current research that these scientists are doing. Even the traditional memorization of lots of details about basic cell structure and function is probably unnecessary; after 5 years of non-use students likely retain only 10% of what they learn; even if they need 10% -- or more – in their future careers, there is no likelihood that it will be the same 10%. We have to do a better job has of determining what portion of the information currently taught in the “basic sciences” is crucial for all future doctors to know and memorize, and we also need to broaden the definition of “basic science” to include the key social sciences of anthropology, sociology, psychology, communication, and even many areas of the humanities such as ethics. This is not likely to happen in a curriculum controlled by molecular biologists.

Medical students need a clinical education in which the most common clinical conditions are the most common ones they see, the most common presentations of those conditions are the most common ones they see, and the most common treatments are the ones they see implemented. They need to work with doctors who are representative, in skills and focus, of the doctors they will be (and need to be) in practice. Clinical medical education seems to work on the implicit belief that ability to take care of patients in an intensive care unit necessarily means one is competent to take care of those in the hospital, or that the ability to care for people in the hospital means one can care for ambulatory patients, when in fact these are dramatically different skills sets.

This is not to say that we do not need hospitals and health centers that can care for people with rare, complicated, end stage, tertiary and quarternary disease. We do, and they should have the mix of specialists appropriate to them, more or less the mix we currently have in AHCs. And it is certainly not to say that we do not need basic research that may someday come up with better treatments for disease. We do, and those research centers should be generously supported. But their existence need not be tied to the teaching of medical students. The basic science, and social science, and humanities that every future doctor needs to learn can be taught by a small number of faculty members focused on teaching, and does not need to be tied to a major biomedical research enterprise. Our current system is not working; we produce too many doctors who do narrow rescue care, and not enough who provide general care. We spend too much money on high-tech care and not enough on addressing the core causes of disease.

If we trained doctors in the right way in the right place we might have a better shot at getting the health system, and even the health, our country needs.

Dead Man Walking: People still die from lack of health insurance

At the recent meeting of the Association of American Medical Colleges (AAMC) meeting in Philadelphia, Clese Erikson, Senior Director of the organization’s Center for Workforce Studies, gave the Annual State of the Workforce address. It had a great deal of information, and information is helpful, even if all of it is not good. She reported on a study that asked people whether they had always, sometimes or never seen a doctor when they felt they need to within the last year. On a positive note, 85% said “always”. Of course, that means 15% -- a lot of people! – said “sometimes” (12%) or “never” (3%). Of those 15%, over half (56%) indicated the obstacle was financial, not having the money (or insurance). There are limitations to such a survey (it is self-report, so maybe people could have gone somewhere, like the ER; or maybe they asked your Uncle George who would have said always because he never wants to see a doctor even though you think he should for his high blood pressure, diabetes, and arthritis!) but it is not good news.

Of course, as former President George Bush famously said in July, 2007, "I mean, people have access to health care in America. After all, you just go to an emergency room." Many of us do not think that this is a very good solution for a regular source of care in terms of quality. Also, if you have had to use the ER regularly for your care and already have a huge unpaid stack of bills from them, it can make you reluctant to return. This likely contributes to the “sometimes” responses, probably often meaning “sometimes I can ride it out but sometimes I am so sick that I have to go even though I dread the financial result.” Following this ER theme, another leading Republican, Mitt Romney, declared repeatedly during the 2012 Presidential campaign, that “No one dies for lack of health insurance,” despite many studies to the contrary. And despite the fact that as Governor of Massachusetts he presumably thought it was a big enough issue that he championed the passage of a model for the federal Affordable Care Act in his state.

People do, in fact, die for lack of health insurance. They may be able to go to the ER when they have symptoms, but the ER is for acute problems. Sometimes a person’s health problem is so far advanced by the time that they have symptoms severe enough to drive them to the ER that they will die, even though the problem might have been successfully treated if they had presented earlier. Or, the ER makes a diagnosis of a life-threatening problem, but the person’s lack of insurance means that they will not be able to find follow-up care, particularly if that care is going to cost a lot of money (say, the diagnosis and treatment of cancer). If you doubt this still, read “Dead Man Walking”[1], a Perspective in the October 12, 2013 New England Journal of Medicine, by Michael Stillman and Monalisa Tailor (grab a tissue first).

We met Tommy Davis in our hospital's clinic for indigent persons in March 2013 (the name and date have been changed to protect the patient's privacy). He and his wife had been chronically uninsured despite working full-time jobs and were now facing disastrous consequences.

The week before this appointment, Mr. Davis had come to our emergency department with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had cost him $10,000 (his entire life savings), and at evening's end he'd been sent home with a diagnosis of metastatic colon cancer.

Mr. Davis had had an inkling that something was awry, but he'd been unable to pay for an evaluation...“If we'd found it sooner,” he contended, “it would have made a difference. But now I'm just a dead man walking.”

The story gets worse. And it is only one story. And there are many, many others, just in the experience of these two physicians. “Seventy percent of our clinic patients have no health insurance, and they are all frighteningly vulnerable; their care is erratic.”  And the authors are just two doctors, in one state, a state which (like mine) starts with a “K” and (like mine) is taking advantage of the Supreme Court decision on the ACA to not expand Medicaid, and which (like mine) has two senators who are strong opponents of ACA, which means, de facto, that they are opposed to ensuring that fewer people are uninsured. I cannot get their thinking, but it really doesn’t matter, because it is ideology and they have no plan to improve health care coverage or access. So people like Mr. Davis will continue to die. This same theme is reflected in a front-page piece in the New York Times on November 9, 2013, “Cuts in hospital subsidies threaten safety-net care” by Sabrina Tavernise:

Late last month, Donna Atkins, a waitress at a barbecue restaurant, learned from Dr. Guy Petruzzelli, a surgeon here, that she has throat cancer. She does not have insurance and had a sore throat for a year before going to a doctor. She was advised to get a specialized image of her neck, but it would have cost $2,300, more than she makes in a month. ‘I didn’t have the money even to walk in the door of that office,’ said Ms. Atkins.

In a recent blog about the duration of medical education, I included a graphic from the Robert Graham Center which show the increased number of physicians that the US will need going forward, mostly as a result of population growth but also from the aging of that population, along with a one-time jump because of the increased numbers people who will be insured as a result of ACA (this will, I guess, have to be adjusted down because of the states that start with “K” and others that are not expanding Medicaid). Ms. Erikson included this graphic in her talk at AAMC, with numbers attached. Just from population growth and aging, we will require about 64,000 more physicians by 2025 (out of 250,000-270,000 total physicians).The one-time jump because of the ACA is about 27,000, bringing the number to 91,000.

But, of course, there is a big problem here. The projection that we will need more doctors because we have more people, or because our population is aging and older people need more medical care, is one thing. But the need for more doctors because more people will be insured? What is that about? Those people are here now, and they get sick, and they need care now, no less than they will when they are covered in the future. I do not mean to be critical of the Graham Center or Ms. Erikson for presenting those data. I do, however, think that we should emphasize how offensive is the idea that we will need more doctors just because more people will have coverage. They didn’t need doctors before, when they didn't have insurance?

If there are people who cannot access care, we need to be able to provide that care. We will need more health care providers, including more doctors, especially more primary care doctors. We need health care teams, because there will not be enough doctors, especially primary care doctors. We need the skills of health workers who can go to people’s homes, and identify their real needs (see the work of Jeffrey Brenner and others (see Camden and you: the cost of health care to communities, February 18, 2012). We need to ensure that people have housing, and food, and heat, and education – to address the social determinants of health.

Decades ago, I heard from someone who visited Cuba a few years after the revolution. He said he mentioned to a cab driver the dearth of consumer goods, such as shoes, in the stores. The cab driver said “we used to have more shoes in the stores, but now we first make sure that they are on children’s feet before we put them in stores windows.” There was enough before the revolution, enough shoes and enough milk, as long as a lot of people were not getting any. The parallel is that now, in the US, if we seem to have enough health clinicians, it is because there are lots of people not getting health care.

This is not ok. It isn’t ok with the ACA, and it isn’t OK without it.

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[1] Stillman M, Tailor M, “Dead Man Walking”, Michael Stillman, M.D., and Monalisa Tailor, M.D.

October 23, 2013DOI: 10.1056/NEJMp1312793

The role of Primary Care in improving health: In the US and around the world

At the Family Medicine Midwest conference held recently in Milwaukee, the first day’s plenary speaker was Richard Roberts, MD, from the University of Wisconsin. Dr. Roberts has a distinguished history as a health services researcher and leader in Family Medicine, having been president of both the American Academy of Family Physicians (AAFP) and the World Organization of Family Doctors (WONCA). He has extensive experience in international health, and is knowledgeable about the health systems – and their results – in countries around the world. And he continues to practice family medicine.

Some of the issues that Dr. Roberts discussed involve the health care system, and, drawing from the important work of the late Dr. Barbara Starfield, emphasize the importance of primary care to improving the health of a population. I have written about the disproportionate emphasis of medical education on hospital care, advanced disease, and high-cost rescue interventions which often fail to rescue and frequently cause complications, rather than on primary care, prevention, and early diagnosis and treatment. Dr. Roberts reminds us of the “Ecology of Medical Care” (referring to the

setting in which health care takes place), done first by Kerr White in 1961[1] and replicated by the Graham Center of the AAFP in 2003[2] with remarkably similar results. In a community of 1000 adults, in any month about 800 have a health problem or injury, 217seek attention from a doctor, 8 are hospitalized, 5 see subspecialists, and 1 or less is admitted to an academic medical center teaching hospital, which, of course, is where we train most medical students and residents, and where they get a skewed view of the prevalence of disease. They begin to see unusual or even rare things as common, and develop habits of ordering tests that are perhaps appropriate in that setting, but dramatic overuse in ambulatory practice.

In 2005, there were 34 million hospital admissions in the US, but almost 1 billion office visits. Of those, about 53% were to primary care physicians. While much is made of the increase in emergency department usage, from 1995 to 2005 ER visits were up 8% while primary care visits increased 22%. As Roberts notes (medical students should cover their ears!) primary care doctors comprise about ¼ of the physician workforce but see more than ½ of all patient visits and earn about ½ the income of subspecialists (and this is average; a much smaller fraction of the income of the most highly paid subspecialists).

Internationally, the same trends are noted. Countries with a higher “primary care score” (which largely measures the percent of the medical workforce in primary care) had lower rates of premature deaths than those with low PC scores in 1970, and over the last 4 decades, while the rate has gone down in both groups, the gap between them has widened. In an unintended “natural experiment”, the Asian economic boom of the early 1990s allowed Indonesia to greatly increased health spending, mostly in primary care; that nation saw a 70% improvement in health status in all provinces. With the collapse of that “bubble” in the late 1990s, spending on primary care went down, but not on hospital care in the big cities. This was a result not of Indonesian government decisions, but rather of the international community through organizations such as the World Bank saying “your economy is worse, but you need health care – here’s money … to build hospitals”. But health status dropped in most provinces. Not the best use of resources!

In the 1990s, Shi studied socioeconomic, environmental, and health system characteristics of US states and their relationship to health status (mortality, lifespan, deaths due to heart disease and cancer, neonatal mortality, and low birthweight). Access to primary care was the strongest predictor of greater lifespan and was second (to living in an urban area) for lower mortality rates, even ahead of education. Number of specialists and number of hospital beds were far down the list – indeed they were negative predictors![3] None of the changes in the health system since that time are likely to change this; indeed, the increase in specialists, technology, and hospitalizations have probably increased it.

What is it about primary care? Why does it make so much difference. Starfield’s work identified the fact that nations and regions with high levels of primary care have greater self-reported health status and fewer health disparities, and that the presence of primary care tends to mitigate the negative impact of income inequality.[4] This group also demonstrated that an increase of primary care physicians of 1 per 10,000 (20%) physicians decreases mortality by 40 per 100,000 (5% fewer deaths), and 1 per 10,000 (33%) more family physicians decreases mortality by 70 per 100,000 (9% fewer deaths), while an increase in specialists of 1 per 10,000 (8%) increases mortality by 16 per 100,000 (2% more deaths). [5] Dr. Roberts notes 4 features of systems with higher primary care to specialist ratios that might affect this: 1) when there are too many specialist and not enough primary care doctors, specialists may try to manage conditions outside their specialty in which they are not knowledgeable; 2) prevention and early detection save more lives and extend life more than intervention late in the disease process; 3) there is excessive utilization of procedures when there are too many specialists (supply drives demand rather than vice versa) and these often have risks; 4) the more “handoffs” there are between doctors caring for a patient, the more that care begins to resemble an elementary school game of “telephone”, where the final message heard is very different from that which began the communication.

The fact that family physicians specifically seem to improve population health status more than primary care physicians taken as a whole is apparent in the data, but the reason has not yet been identified by studies. Dr. Roberts postulates that it has to do with caring for multiple family members, and using that information to improve their care, such as when a mother’s issues are addressed at a visit ostensibly limited to caring for her child. Primary care (and possibly especially family physicians) acts to achieve all aspects of what has been identified as the “Triple Aim” of health care: greater access, lower cost and higher quality.

Primary care doctors, and especially family physicians, are doctors of “first and last resort”. They care for pregnant women and deliver their babies and care for their children as well as the other adults in the family. They tend to the “grandparents”, older adults, and manage the often complex interplay of multiple chronic diseases. They provide acute care and preventive care and are aware of the individual’s beliefs and preferences and those of the family, and the dynamics that exist between them. They care for people at the end of life, right through the end, not just until “there is no more to do”, and they remain there for the survivors.

The US could do a lot better. We need a health system that is more grounded in primary care, and we need a health system that provides access to everyone. What we don’t need is folks in Congress are committed so committed to preventing that access they will shut the government down!  Another conference speaker, Dr. Cynthia Haq of the University of Wisconsin, quoted the Ethiopian Minister of Health, with whom she had recently met. “Only in the United States,” the Minister said, “could there be discussion about whether access to health care was a human right or not.”

Oh, my. He’s right. I sure wish he were not.

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[1] White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885–892.

[2] Green, LA et al., “The ecology of medical care revisited”, N Engl J Med 2001; 344:2021-2025June 28, 2001DOI: 10.1056/NEJM200106283442611

[3] Shi L, "Primary care, specialty care, and life change", Intl J of Health Service,1994; 24(3):431-58

[4] Starfield BA, Shi L, Macinko J, “Contribution of Primary Care to Health Systems and Health”, Milbank Quarterly Sept2005; 83(3):457-502. DOI: 10.1111/j.1468-0009.2005.00409.x

[5] Shi L, et al., “The Relationship Between Primary Care, Income Inequality, and Mortality in US States, 1980–1995”, J Am Bd Fam Med, 1Sep2003;16(5)412-422. doi: 10.3122/jabfm.16.5.412.

Why don't graduate medical education programs produce the doctors America needs?

In 2010, Fitzhugh Mullan and others from the George Washington University, with collaborators from the American Academy of Family Physicians' (AAFP) Robert Graham Policy Research Center, published the seminal article “The social mission of medical education: ranking the schools” in the Annals of Internal Medicine (discussed in this blog on June 10, 2010 in A New Way of Ranking Medical Schools: Social Mission).  This paper looked at the production of medical schools in the US in terms of whether their graduates were in 3 categories associated with social mission: practice in an underserved area, practicing a primary care specialty, and having a higher percentage of graduates who were members of underrepresented minority groups.  It was the first time such data had been published, and the results showed that most medical schools don’t do very well, and that, in general, those that do the worst are those most often identified as “top” schools by criteria such as National Institutes of Health (NIH) funding or rankings by US News. This is not surprising; enrolling students from high income families who have had top grades at the most elite private and suburban schools, training them in a setting in which the mix of doctors is heavily skewed to the most subspecialized and research-intensive, located in a densely populated urban area, is the precisely wrong formula for recruiting physicians from underserved backgrounds and training them to practice primary care in areas of need. Unfortunately, although there have been small programs implemented at many schools, this model has not seen any significant change in most medical schools, particularly those “most elite”.

This year, this group from the Graham Center and George Washington, with collaborators from the the American Board of Family Medicine (ABFM), take the next obvious step in examining the production of the nation’s doctors. In “Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions”,[1] in Academic Medicine (not available free on-line; abstract at http://www.ncbi.nlm.nih.gov/pubmed/23752037), Candice Chen and her colleagues look at how institutions that sponsor GME (and, importantly, get very large amounts of money from Medicare and Medicaid -- $9.3 billion and $3.18 Billion, respectively, in 2009) do in producing specialists in short supply: primary care physicians (defined as family medicine, general internal medicine (GIM), general pediatrics, internal medicine–pediatrics, internal medicine geriatrics, and family medicine geriatrics), general surgeons, obstetrician - gynecologists and psychiatrists. Identifying which program produced who is quite a bit harder than when looking at medical school outcomes; while a medical school is a medical school, GME-sponsoring institutions can be consortia of a medical school and one or more hospitals, and may often sponsor more than one residency program in the same specialty.

As in all measures of primary care production, the big complication is in graduates of internal medicine programs, the majority of whose graduates go into subspecialty (e.g., cardiology, gastroenterology, pulmonary and critical care) fellowships rather than remaining in primary care/general internal medicine (GIM). Chen’s work accounts for this, but explicitly notes that they are unable to account for the percent of GIM graduates who do not go on to subspecialty training but work as hospitalists. These are clearly not in primary care, and by many accounts may represent a majority of those completing the basic internal medicine training but not going on to fellowship. The authors note that, by their calculations, the average for primary care was 25.2%,”… this overestimates primary care production, as we could not account for primary care physicians practicing as hospitalists.”

Just as with medical schools, there was a wide variation in the percent of graduates of different sponsoring institutions who entered these specialties-in-need. Of 759 sponsoring institutions, they ‘…found that 158 institutions produced no primary care graduates, and 184 institutions produced more than 80%; the latter tended to be smaller institutions.” Again no surprise; the larger, more elite and famous sponsoring institutions (most often hospitals associated with elite medical schools) did a terrible job, while the smaller sponsoring institutions -- often hospitals with one (usually family medicine) or a few residencies, in smaller cities and towns, and affiliated with Federally-Qualified Health Centers (FQHCs) or Area Health Education Centers (AHECs), based in in underserved urban and rural communities, did well. The Robert Graham Center website provides interactive tools to allow you to map the density of primary care physicians by state, county and other areas, the output of each institution producing residents in terms of location and specialty, and the footprint of graduates from each GME program.

Let me restate: 158 institutions sponsoring graduate medical education produced NO primary care graduates! Let’s add some other numbers from the study: 198 institutions (more than 25% of the total) produced NO rural physicians, while only 10 institutions had all graduates go to rural areas; the average percentage of graduates providing direct patient care in rural areas was 4.8%. 283 institutions (37%) produced NO physicians practicing in FQHCs or rural health clinics (RHCs); 479 (63%!) institutions produced no National Health Service Corps (NHSC; a program for sponsoring physicians for underserved areas) physicians. This performance can be described by a single, simple word: ABYSMAL!

Elite academic medical centers have values that lead them to attract and select students and trainees with characteristics that are the opposite of those needed for training physicians to meet the needs of the American people. They value caring for rarer and highly specialized tertiary and quarternary conditions, which both are highly reimbursed and provide the basis for research in narrow areas of disease (and almost never of health). They value receiving large sums of money from the National Institutes of Health (NIH) for research, most of which is basic laboratory research. These are not bad values; they are, in fact, necessary. We need research, including basic laboratory research and first-in-human studies, for medical science to advance (although we also need a lot more funding for population-based research into the causes of health and disease, and community-based efforts to address them). We need tertiary-care medical centers where rarer or more complex conditions can be most effectively treated by physicians and surgeons whose narrower expertise makes them more experienced and effective.

The problem is that concentrating all these subspecialists in the very places where students and residents are trained gives those learners a very skewed idea of the ratio of subspecialists to primary care doctors, and makes the teachers want to get the “best” students to go into their narrow, subspecialized areas. In addition, selection for medical school (and to a large extent for residencies that are more competitive because they have fewer slots) tend to be for students who have the characteristics that help them to do well in basic science courses, standardized tests, and possibly in laboratory research. These students tend to come from the highest income families of professionals, in the largest metropolitan areas, from elite public or suburban schools. They look a great deal like the people who have plenty of doctors to care for them, and very little like the people whose communities suffer from a dearth of physicians in inner city and rural areas. I have previously noted that, while about 20% of Americans live in rural areas, only about 9% of doctors practice in such areas; this study shows it is actually much worse, with only 4.8% of graduates in rural practice!

The situation is exacerbated by the inequity in income between primary care doctors and subspecialists, an inequity also seen (albeit at a higher level) for general surgeons vs. subspecialty surgeons, especially when hours of work are considered. Thus, students, generally selected from a population not representative of the American people, who have increasing debt (even for those from upper-middle-income, not to mention middle-income and the rare student from low income families), are attracted to specialties that pay the most; if assessments of “lifestyle” are added to the calculus, those that pay the most for the least work (or whose income/work ratios are the highest). This is a formula to continue what we have, not to make things better.

The authors of the paper say that “Primary care physician production of 25.2% and rural physician production of 4.8% will not sustain the current workforce, solve problems of maldistribution, or address acknowledged shortages. The relatively small number of physicians choosing to work in RHCs, FQHCs, HPSAs, and the NHSC will not support a doubling of the capacity of safety net services envisioned by the

Affordable Care Act.” They have that right. Medical schools and GME-sponsoring institutions have for too long been allowed to continue being self-serving, with the biggest institutions being entirely pitiful in terms of producing the doctors America needs. It needs an immediate, far-reaching, large-scale change, where the biggest training programs see themselves in the business of producing primary care doctors for underserved people.

Why would they do that? Well, there is the $9.5 billion in Medicare and $3.18 billion in Medicaid GME funding that could be withheld if they don’t, for a start…

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[1] Chen C, et al., “Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions”,  Academic Medicine, Vol. 88, No. 9 / September 2013

Creating team based care: are non-physician providers more effectively used in primary or subspecialty care?

The shortage of primary care physicians in the US, which I have often discussed (most recently in “When is the doctor not needed? And who should take their place?”, January 5, 2013), has become a national theme. The Robert Graham Center of the American Academy of Family Physicians (AAFP) has done much of the work in documenting this shortage, such as in the article “Projecting US Primary Care Physician Workforce Need” by Petteson, et al., discussed in my post “Health reform, ACA, and Primary Care: Is there still a conundrum?”, December 24, 2012. Essentially the problem is we have too few primary care doctors for the current population, the demand for them will continue to grow, and the rate of production (medical students entering primary care specialties) is below that even needed to replace those who retire. The growth in demand is a result of (in order of impact): population growth, aging of the population, and a more-or-less-one-time blip from increasing coverage under ACA (although for the latter, the people with a need for care were already there; it is just that with having insurance they will be able to seek it more easily).

 In a recent issue of Health Affairs, Green and colleagues argue that “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication “.^[1] This is not a new concept; it is a central component of what is known as the “Patient Centered Medical Home”. The article suggests that many functions now carried out by physicians can be done by others, ranging from nurse practitioners and physician’s assistants, to nurses, to others on the health care “team”. It also suggests that many problems that now require face-to-face communication (trips to the doctor’s office) could be done by phone or “virtually”, such as by structured email or web-based visits. Thomas Bodenheimer and his colleagues in San Francisco have done much of the work in this area, most recently published in Annals of Family Medicine “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation”.[2]

Green, et al., use computer simulation models to estimate the “panel size” (number of patients that can be cared for per doctor) by the employment of such techniques; they add calculations for “pooling” of physicians, that is, sharing of patients among a group of doctors. This allows greater efficiency by “smoothing out the bumps” that may occur when one physicians has more or fewer patients coming in for same-day care or not showing up for their appointments by allocating them among the group. Using these statistical models they estimate that the ability of patients to access care (get in to be seen) would be dramatically increased by the implementation of such policies.

The work done by both the Green and Bodenheimer groups is convincing, and provides a model for more efficient primary care practice that would help to address the problems our country faces from having too few primary care doctors. Indeed, these approaches utilize the “crisis” as a way to actually improve both access to and quality of patient care. There are, however, challenges to implementation of this model. One is payment; while health systems in many parts of the nation have demonstrated that it is possible to restructure their practices to achieve these advantages, this is most effective in settings in which the provider is also the insurer (notably Kaiser). In those parts of the country where this model of care is less prevalent, where most payment to medical providers is “fee for service” for face-to-face visits to doctors, there is not only no incentive to change, there is a large negative financial incentive since any non-face-to-face care is, essentially given out free.

A second challenge is that such models only work where there is a large enough concentration of patients and providers to achieve the benefits of scale; as with most such analyses, it leaves out the needs of rural populations. Some large systems, such as Geisinger in Pennsylvania, have been successful in creating such efficiencies in their clinics in rural areas, but Geisinger is atypical; there are not many like it. In addition, it is a financially integrated system (like Kaiser) – that is, it is also the payer -- and it works in a relatively-densely populated rural area of northeastern Pennsylvania, not like the vast empty frontier counties of the West.

It is interesting to me that so much of this emphasis on efficiencies, and particularly the use of professionals other than physicians to provide care, has been on primary care. This, I am sure, is due in part to the need for primary care in all settings, while much specialty care can be centralized in larger cities. It is also because there is not a shortage of many non-primary-care specialists for the needs of the population (although there are for some, such as general surgery, especially in non-urban areas). The reason usually given for this non-shortage is largely that these specialists make so much more money than primary care doctors, so medical students are attracted to them. To the extent that some specialties also have more regular work hours and a limited scope of work, it may also increase their attractiveness.

The limited scope of work (although not, necessarily, less difficult work, especially when considering surgical interventions) also makes them, in many ways, more appropriate fields to use non-physician professionals than primary care. This is the reverse of the usual assumptions that sub-specialists are seeing difficult problems, while primary care providers see mostly colds and blood pressure checks. In fact, primary care is complex, as it sees both undifferentiated patients and those with multiple chronic diseases. Most specialty care is more routine, seeing a much more limited set of diagnoses with a more limited set of interventions; for the typical subspecialist, less than a half dozen diagnoses may account for 80% of visits, while for a family doctor the top 20 are probably 30%. Thus, the breadth of knowledge and skills in making complex decisions and appropriately prioritizing problems, require a level of sophistication and training not taught or developed in most other health professionals (family nurse practitioners are one other provider group where there is at least an effort to have this breadth of training). It is, then unsurprising that most of the tasks suggested for nurses and others to increase the efficiency of primary care practices have limited scope: maintaining disease registries, calling for recommended preventive care, screening a small set of diagnoses.

This type of narrow, in-depth scope of work is much more characteristic of subspecialty care, and it is one of the reasons why expanded-scope nurses and physician’s assistants have found so much use in these practices. They follow people with congestive heart failure for cardiologists or diabetes for endocrinologists, they manage chemotherapy recipients for oncologists, they use algorithms to care for people in intensive care units, they do pre- and post-operative care for orthopedists and other surgeons. And they do not go outside of the set of diagnoses and treatment options with which they are familiar; following the model of the physicians with whom they work, when a patient’s problem is not in their narrow area, it is referred.

The targeted but limited expertise of such nurse specialists have explains why they function so well clinically in subspecialties. What explains why it works financially is that the doctors (or hospitals, or health systems) that employ them are reimbursed at subspecialist physician rates (already very high) for work that is done by others; thus they can afford to pay such “physician extenders” relatively well compared to folks working in primary care. Reimbursement for “teams” follows the model of reimbursement for physicians: care for a limited set of diagnoses in a detailed way, especially when it involves procedures, is paid much better than management of complex sets of interactive diagnoses.

Unfortunately, the problem with such practice is challenging because the same person often has multiple conditions, and interventions that help one may make another worse. While efforts to build teams, and have each professional work at the “top of their license”, is important, so is payment. As long as primary care is reimbursed at lower rates it will continue to face challenges in recruitment of physicians, nurses, and other team members. 

We need to develop and implement great strategies for team-based care. We also need to dramatically decrease the ratio of income for subspecialists and their subspecialist teams relative to those working in primary care.

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[1] Green LV, Savin S, Lu Y, “Primary Care Physician Shortages Could Be Eliminated Through Use Of Teams, Nonphysicians, And Electronic Communication”, Health Affairs, 32, no.1 (2013):11-19

doi: 10.1377/hlthaff.2012.1086

[2] Altschuler J, Margolius D, Bodenheimer T, Grumbach K, “Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation” , September/October 2012 vol. 10 no. 5396-400 doi:10.1370/afm.1400

Health reform, ACA, and Primary Care: Is there still a conundrum?

Now that the election is over and the fact of the Affordable Care Act seems assured by the victory of the President and the increase in the Democratic majority in the Senate along with the Supreme Court’s upholding of most of the ACA’s provisions, the characteristics of change in the health care system (or, as I have often noted, non-system) can begin to be outlined. In my last post (November 17, 2012), I took note of the fact that even if the ACA is fully implemented there will be 30 million uninsured. If the states (mostly controlled by Republican governors and legislatures, including my own, Kansas) that have threatened to not participate in Medicaid expansion actually do not (and they can refuse; this is the part of ACA that the Supreme Court decision overturned), that number will be higher. But, clearly, there will be a large increase in the number of Americans with insurance coverage.

The big “systems” question is “How should health care delivery systems in the US re-engineer to deliver more efficient, more cost-effective care to more people for less money?” The key answer here is “more primary care”. Systems built around primary care have higher quality and lower cost than those which are built around specialty and sub-specialty practice. This has been recognized by the large health systems that do exist in the US (prototypically, Kaiser, but also others such as Geisinger in Pennsylvania, Cleveland Clinic, Inter-Mountain Health, and the model used in Grand Junction, CO) which are built around a large primary care base. They also have expanded services to support the practitioners (family physicians, most commonly, but also general internists, general pediatricians, and primary care nurse practitioners and physician’s assistants), which include many duties that do not have to be done by the physician (or NP or PA) being discharge by nurses, pharmacists, social workers and even community health workers.

Such organizations can do this because their systems are large enough, and because its expenditures in one area (say, higher salaries for primary care, or employing community health workers or more nurses, or more pharmacists) realize greater savings in other parts of its balance sheet. It works particularly well for Kaiser, because they are also the insurance company. This is what can happen with central planning and resource allocation, and provides some of the economic justification for a single-payer health system. In the current setup, especially in parts of the country less penetrated by large health systems, it can remain “everyone for themselves”. If the same organization does not control the primary care, specialty care, and hospital care, investments in one area will not necessarily result in savings in another.

The hope of ACA is that it will encourage even the most recalcitrant, specialist-dominated, fee-for-service communities to form such integrated models, called “Accountable Care Organizations”, or ACOs.    If these are to work, it will have to mean more primary care and fewer expensive (and profitable to the providers) procedures. The “primary care conundrum” is really two: there are not enough primary care providers (physicians, NPs, PAs) to meet the current demand, not to mention that which will arise in part from expansion of coverage but even more from expansion and aging of the population (see Petterson et al. “Projecting US Primary Care Physician Workforce Need [1]), and in most parts of the country the financial incentives are not in favor of students entering primary care, so this imbalance will increase.

Some communities, and even some academic health centers, are actively and aggressively moving toward the creation of ACOs; an excellent recent article in Health Affairs by Al Tallia and Jenna Howard [2] describes both the progress and the challenges of one AHC’s efforts to do so. The complexities and competing interests that exist in a situation such as that in New Jersey are a far cry from the integrated Kaiser model, but the obstacles appear as if they can be overcome, especially when, as under many of the provisions of ACA (most particularly not reimbursing hospitals for readmissions), the financial incentives are aligned.

The creation of additional primary care providers is going to be a longer haul. Payments for primary care are rising significantly in the same parts of the country where integrated health systems are dominant, as illustrated by quotes from a couple of family medicine chairs:

<    •       “…family physician salaries are going up quickly in Northeast Ohio. At Cleveland Clinic we have raised salaries of all family physicians by an average of 24% in the past 4 years.” (John Hickner)

\    •       n my neck of the woods (CA), there is huge unmet demand specifically for family physicians and enlightened organizations like Kaiser are paying handsome salaries (stunningly so) for FP grads fresh out of residency, and also offering loan repayment.”

But this is certainly not uniform across the country, and even in these areas, despite such big increases, the earnings of a family doctor are much smaller than those of many other specialists. (Hey, a 24% increase is good, but when previously your income was 1/3 of some subspecialists, it still leaves a large gap.) Research by the Robert Graham Center [3] suggests that income no longer plays a role in specialty choice when the lower-paid specialty earns 70% or more of the higher paid. More significantly, even if there is great movement into primary care, it will take decades to begin to approach the 50% ratio in the overall workforce.

So, we are left with good news and bad news. The good news is that more people will be covered; the bad news is that there will still be many left out. The good news is that in some parts of the country integrated health systems are demonstrating cost-effective ways of delivering health care and rewarding the primary care workforce; the bad news is that it is not by any means consistently happening across the country. The good news is that this seems to work best not only when every patient involved is insured, but when the expenditures and savings are realized by the same organization; the bad news is that there are lots of people outside of such a system and lots of places where medical practice is still “everyone for himself”. The good news is that there is increasing recognition of the importance of primary care practice; the bad news is primary care incomes still lag seriously behind that of many other specialists while medical school debt is rising. The good news is that team-based care is the most effective model; the bad news is that there is still inter-professional and inter-disciplinary competition rather than collaboration.

We can work to turn the bad news into good. But we must keep our eyes on all the problems, not just a few. The cost-effective, high-quality health systems that are developed will not be truly good news until everyone benefits from them.

 

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[1] Petterson S, et al., “Projecting US primary care physician workforce needs: 2010-2025”,Ann Fam Med 2012;10:503-509. doi:10.1370/afm.1431

[2] Tallia A, Howard J, “An Accountable Care Organization An Academic Health Center Sees Both Challenges And Enabling Forces As It Creates An Accountable Care Organization”, Health Affairs, 31, no.11 (2012):2388-2394

[3] Check out this very cool “Primary Care Mapper” from the Graham Center.