The State of US Health: improved over 20 years, but not nearly enough

An enormous, and enormously important, study was recently published online-ahead-of-print in JAMA describing the state of health in the US and comparing it that in other 33 “developed” countries in the Organization for Economic Cooperation and Development (OECD). “The State of US Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors”[1] was written by the members of the US Burden of Disease Collaboration, an enormous group of population-health scholars from institutions across the country and a few from other parts of the world. The methods used are incredibly complex; indeed editorialist and President of the Institute of Medicine (IOM) Harvey V. Fineberg, MD PhD (“The State of Health in the United States”)[2] calls it “…an arcane and complex process, and despite the authors’ best efforts to explain their methods and make data available, few readers will fully understand how the results are derived.” Nonetheless, the findings are incredibly important.

Here are the main results:

Since 1990, the health status of the US has improved in most areas.

·         Average life expectancy has increased, from 75.2 to 78.2 years;

·         Healthy life expectancy (HALE) has increased, from 65.8 to 68.1 years;

These are good things; that is, they are moving in the right direction. However, they are moving in the right direction more slowly than in the other OECD countries, so that, since 1990, the US rank for life expectancy (at birth) has dropped from 20^th to 27^th among these 34 countries, and the HALE has dropped from 14^th to 26^th!

A few more terms, not that hard to understand: Life expectancy is decreased by the years of life lost through premature (age-standardized) death due to disease or injury (YLL). The difference between absolute life expectancy and HALE is the number of years lived with disability (YLD). The sum of YLL and YLD is expressed as disability-adjusted life years (DALY), kind of the complement of HALE. That is, the lower the DALY, the fewer years of life have been either lost to premature death or lived with disability. From 1990, the US rank among the OECD countries has dropped in all these areas:

·         From 18^th to 27^th in age-standardized death rate;

·         From 23^rd to 28^th in YLL;

·         From 5^th to 6^th in age-standardized YLD.

These are not good things. The table indicates, for each of the 34 countries, the rank for YLL for each of 25 conditions: green means significantly better than the mean, yellow about the mean, and red significantly worse. The US is green in only one (stroke), and is red in 15!

The other important thing done by the study’s authors was to look at risk factors for YLL and YLD in the US. As Fineberg explains, this is a complicated and difficult task,”…attempting to estimate the contribution of each risk factor to premature death.” It is easier to measure mortality (death) than morbidity (disability), but it is important because, as noted in the abstract, “As the US population has aged, YLDs have comprised a larger share of DALYs than YLLs.” That is, years lived with disability exceeds years of life lost from treatable disease. This makes sense; as we have developed increasingly sophisticated (and costly) high-tech interventions to prevent death (discussed by me, for example, in Primary Care Contributes More than Money..., June 2, 2013), we have increased the number of years that people are kept alive but suffering from the symptoms and complications of their diseases. The article's abstract contains 4 sentences that describe this:

• “The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury.
• Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls.
• The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders….
• The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use.”

The largest number of YLLs were caused by the “traditional” chronic diseases, while most of the conditions that increased YLL over the last 20 years were those that one would expect to increase as we keep people alive longer, particularly Alzheimer’s disease, chronic kidney disease, falls, and drug use disorders (which includes not just “illicit” or “illegal” drug use, but those taking prescription drugs, in particular for chronic pain – which comprise a large proportion of the diseases that have the largest number of YLDs -- back pain, other musculoskeletal disorders, neck pain).

These findings should guide our population/public health interventions. And the leading risk factors for DALYs are not surprising; they are the ones that we hear about all the time: dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. These are the very areas, in fact, where most population/public health programs are currently focused. However, when it comes to public policy, laws, and spending money to try to solve the problems, we are woefully deficient in the US. There has been some success in regulation of smoking in public places although not without significant resistance from those who profit from tobacco, including the tobacco industry, tobacco retailers, and clubs and casinos; indeed the public smoking ban passed in my state of Kansas a few years ago is being threatened with repeal. Public interventions in the other areas have had much greater opposition (see New York City’s efforts to limit portion size of sugar-filled soft drinks) or non-existent.

What is popular is victim-blaming, telling people who are overweight, inactive, smokers, drinkers, and victims of diabetes or hypertension to “clean up their acts”, to stop, to lose weight, to adopt healthy habits. Of course, these would be good, and we see increasing numbers of individuals doing so. However, the success rate is much higher among groups with higher income and higher educational levels, which must mean something. It could be that they know that smoking, obesity, inactivity, drinking, drugs, and not taking medicine for diabetes and high blood pressure are bad for you, while poorer people don’t. That, however, is hard to imagine. It is more likely due to their greater level of resources to try to address these problems, social support for healthful behaviors (including jobs), and access to health care. In addition, the same interests that lobby against regulation of smoking, unhealthy foods and alcohol are heavily advertising these same substances in the least-advantaged communities.

The “social determinants of health” are at play here; not only access to health care, but safe communities, stable housing, education, and prospects for jobs – the very things that national and often state policymakers seem to be least willing to fund, and the areas that other OECD countries often do fund. As discussed by Bradley and Taylor  in their book and NY Times Op-ed “To fix health care, help the poor” and by me in my post from December 18, 2011, “To improve health the US must spend more on social services”, the US stands out among OECD countries in that the vast majority of its combined health and social services spending is on medical care. This helps explain both our decrease in YLL from treatable but essentially end-stage medical conditions and our increase in YLD and in risk factors for chronic disease, because, as Bob Bowman described so well in “Moving to Recovery By Design”, June 22, 2013,we do not treat the “upstream” circumstances of people’s lives that lead to “downstream” disability and death. Even the US Burden of Diseases Collaborators have left out discussion of the social issues, which is perhaps on purpose but did not escape Fineberg’s notice: “The most glaring omission in the assessment of risk factors, as the authors acknowledge, is the role of social factors such as income and inequality as a risk of premature death and disability.” It is, as he acknowledges, harder to measure, but that scarcely decreases its relevance.

It is not about the money. We have the money. It is, as I have said before, about the will. About the will of politicians, who are ideologically committed to the principle that the only ones who really deserve government assistance are the largest corporations and wealthiest individuals and have, as Charles Blow has said (“Resonance Resistant”, May 18, 2013), a gag reflex to the word “social”, but also the will of the American people who often seem to value high-cost, high-tech care at the end of life more than healthful nurturing of people at its beginning.

27^th in age-standardized death rate? 28^th in years of life lost? Come on! Where is that old American competitive spirit? We can do it. We know that. Now, we must do it! 

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[1] US Burden of Disease Collaborators, “The state of US health 1990-2010”,  JAMA. 2013;():.  doi:10.1001/jama.2013.13805.  Published online July 10, 2013.

[2] Fineberg HV, “The State of health in the United States”, JAMA. 2013;():-. doi:10.1001/jama.2013.13809, published  online July 10, 2013.

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

Guidelines, bias, and your health

One of the challenges in educating health-care professionals is the massive – and growing -- amount of information about diseases, diagnosis, and especially treatments that are available. This is not only an issue for students and residents, but for continuing education; if a doctor or nurse or pharmacist knows only what they learned in school, it will be outdated in a very few years. Thus, the health professions have committed to the concept of “life-long learning”, but how this happens, and how effective and accurate it is, is the challenge.

With the development of the Internet, information is extraordinarily widely shared very quickly. It makes information available not only to health professionals, but to everyone; in the “old days”, perhaps someone with symptoms, or a new diagnosis, might go to the library, or find an outdated copy of Morris Fishbein’s “Handy Home Medical Encyclopedia” or a similar book. Now they go to the internet and are overwhelmed with information. The problem is that this information may be correct, partially correct, or wrong; it may be complete, incomplete, or valueless. There is a difference between information and truth, and certainly between information and wisdom. Wisdom, and truth, require information, but much  of the information is chaff or worse.

If keeping up with information and sifting through it to discover what is true, relevant, and important is hard for a person who wants to find out about their one condition, it is truly daunting for health professionals who need to keep up on many. There are so many drugs! And new ones all the time! And they are all better, improved, more effective (and certainly more expensive!) than the old ones. Until, of course, we find out that they are not. Or, worse, dangerous. Sometimes so dangerous that they have to be pulled from the market.

In his Op-Ed piece in the New York Times on June 12, 2013, “Healing the overwhelmed physician”, Dr. Jerry Avorn of Harvard Medical School calls this the “Stendhal syndrome”, after the French author who, on an 1817 visit to Florence, “…was seized by palpitations, dizziness and a feeling of being overwhelmed by the abundance of great art surrounding him”; the over-abundance of information, too much to grasp, integrate, and categorize, not to mention utilize effectively.  How can doctors and other health professionals get through this to “truth”? To be able to most effectively help, and, primum non nocere,  not hurt you?

One traditional method, adopted by our friends in the drug industry, has been “detailing”. Pharmaceutical representatives (called, regardless of gender, “detailmen”) fanned out, visiting physicians, giving out free samples of their wares as well as food and pens and sticky-note pads and clocks and calendars and little scale models of whatever organ their drug worked on, along with information about the drug. The information might have been accurate and complete, but often was skewed, and almost always was research funded by the manufacturer. The detailpersons were easily identifiable, even when not pushing a cart full of pizza for “grand rounds” because they were all good-looking and so much more well-dressed than run of the mill health care workers. What a great system! You get information about new drugs, direct from the person selling them, and little scale models of the urinary system and donuts too! Isn’t that how we all hoped our doctors were keeping up with the field of caring for our health?

Well, ethics rules have limited the ubiquity of detailpersons, and free gifts, and even samples; the “educational cruises” to the Caribbean just for being a high-utilizer of a company’s drugs are all but gone. A resident asking a drug rep to fly their whole residency class to Las Vegas for graduation is so last millennium! But an incredibly wealthy industry like the pharmaceutical industry will not give up there. This is the real thrust of Avorn’s op-ed piece. He discusses the influence that these companies have on the development of “clinical guidelines” by groups of experts in a particular medical field.

Clinical guidelines can be really good and helpful. The information glut is real, sifting through all the data is almost impossible for all the conditions that exist, especially ones that are seen rarely by a particular practitioner. It makes sense that a group of experts in the field review all the evidence in that narrow area and make recommendations that we can count on as accurate and can utilize effectively. But we may be reaching a point where there are too many guidelines, often with conflicting recommendations. Avorn focuses on recent recommendations from the American Association of Clinical Endocrinologists (AACE) on caring for patients with diabetes:

“The A.A.C.E.’s latest guidelines elevate many second- or third-line drugs to more prominent positions in the prescribing hierarchy, rivaling once uncontested go-to medications like metformin, an inexpensive generic. They also emphasize the riskiness of established treatments like insulin and glipizide, which now carry yellow warning labels in the A.A.C.E. summary. Several of the now promoted drugs are expensive newcomers that lack the track records of clinical effectiveness and safety held by the older, potentially displaced treatments. The changes were made, ostensibly, to give physicians more treatment choices for their patients. But there is also concern that they could have been influenced by another factor: the manufacturers of some of these new drugs financially supported the development of the guidelines, and many of the authors are paid consultants to some of those companies.”

Avorn goes on to cite previous examples of expert-generated and industry-sponsored guidelines that have led to overuse of drugs with very bad outcomes for patients. He also cites reliable sources of clinical guidelines, which are based solely on review of the evidence, not the opinions (possibly influenced by money) of experts, “…including the Institute of Medicine, the American College of Physicians and the Cochrane Collaboration, an international network of experts that evaluates clinical research.” He also refers to the practice of “academic detailing”, which he helped to develop[1] [2], in which academic physicians and pharmacists try to counter the impact of drug-industry detailpersons by going out to practicing physicians and presenting evidence-based recommendations.

There are at least two other sources of bias in addition to any direct influence exerted by drug company funding of research, guidelines development, and individual experts. One is the fact that many treatments, particularly when they involve procedures, can increase the income of the individual physicians doing them. Unfortunately, we have seen (and continue to see) the persistence of many procedures for which there is weak evidence overall or for as broad a population as it is being used on, presumably for this reason. The other, less overtly money-driven and thus more insidious, is that many experts are, almost by definition, specialists (well described in this context by the more pejorative “partialists”) who are focused on the impact of a treatment on “their” disease and may miss the potential for negative impact on the patient. An example may be very tight control of blood sugar in people with diabetes; it may improve the outcomes from diabetes, but if it also leads to potentially dangerous episodes of low blood sugar, it may not be a good idea.

Guidelines issued by different organizations also may be in conflict. An excellent example is mammographic screening for breast cancer, discussed in two outstanding “Viewpoint” articles in a recent JAMA. Michael Marmot addresses potential benefits and harms from different guidelines, focusing on UK recommendations[3], and Kachalia and Mello look at the differing US recommendations from the US Preventive Services Task Force (USPSTF), American Cancer Society (ACS), and American College of Radiology (ACR).[4] If a radiologist reads a mammogram as normal, but, following ACR guidelines recommends another in one year, while the clinician is following USPSTF guidelines for less frequent screening, does that place the clinician at increased legal risk? They argue at least for consistent guidelines to be utilized within a single institution.

Finally, there is the potential for unintended outcomes. One of the most reliable evidence-based sources of recommendations is the USPSTF. Its recommendations are based solely on review of the science, which has generated controversy before when those recommendations were unpopular with powerful groups (see mammography guidelines). Their reliability led them to be written into the health reform law, ACA, which mandates insurers pay for preventive services with an “A” or “B” recommendation from USPSTF. However, as articulately described by USPSTF members Steven Woolf and Doug Campos-Outcalt in another recent JAMA[5], this creates the unintended consequence of turning USPSTF into a group that decides whether companies and doctors will make money; you can imagine the lobbying by a company to try to prove that its product deserves a “B” rating!

You sure can imagine it. It is not what we need. Essentially, as long as potential for big profit exists in health care, for providers, drug companies, device manufacturers, insurers, and others, there will be plenty of opportunities -- and actual occurrences – of this, not scientific evidence, guiding medical practice.

And I doubt that this is what you want for your health.

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[1] Soumerai SB, Avorn J,  “Principles of educational outreach ('academic detailing') to improve clinical decision making.”, JAMA. 1990 Jan 26;263(4):549-56. PMID: 2104640

[2] Fischer MA, Avorn J, “Academic detailing can play a key role in assessing and implementing comparative effectiveness research findings,” Health Aff (Millwood). 2012 Oct;31(10):2206-12. doi: 10.1377/hlthaff.2012.0817.

[3] Marmot M, “Sorting through the arguments on breast screening” JAMA. 2013;309(24):2553-2554. doi:10.1001/jama.2013.6822

[4] Kachalia A, Mello MM, “Breast cancer screening: conflicting guidelines and medio-legal risk”, JAMA. 2013;309(24):2555-2556. doi:10.1001/jama.2013.7100

[5] Woolf SH, Campos-Outcalt D, “Severing the link between coverage policy and the US Preventive Services Task Force”, JAMA. 2013 May 8;309(18):1899-900. doi: 10.1001/jama.2013.3448. 

Moving to Recovery By Design

The following is a guest post by Robert Bowman, MD, of the A.T. Still College of Osteopathic Medicine in Mesa, Arizona. He welcomes your comments and feedback.

Josh Freeman recently linked to the Charles Blow column in the NY Times, “These Children are our future” (June 14, 2013)  about the past, present, and likely future of the HS Graduating class of 2013 - and those missing from any high school graduation. We were both up into  the wee hours as I also reacted to this with the following:

A classic story taught in most introductory public health classes is of the person who finds the body floating in the river, and pulls it out. Then there are more, and he pulls them out. Then more and more and he gets friends. Then so many that the whole town gets involved, developing a highly efficient system for removing bodies from the river, moving them up and out to the graveyard. Until someone says: "Maybe we should go upstream, and try to find out what is causing all these people to die and fall into the river. And maybe do something about it."

"Upstreamers", then, are those who try to find out why the bodies are getting into the river as compared to those who are focused on addressing problems much later; often too late. Upstreamers recognize social determinant and other barriers that can shape outcomes. For the bottom 30 to 40% of Americans, the outcomes can be shaped substantially by various determinants and not by school, teacher, physician, nurse practitioner, etc. Most of the studies regularly promoted in major journals or reports fail to understand social determinants and patient situations.

Upstream thinking is broken in our nation. Nations with effective social systems have people serving on the front line for health and other social services, who stabilize and support the people of the nation, anticipate their needs, and translate these to national leaders. The role of national leaders is to listen to the people and their translators while acting in the best interest of the nation to make the entire nation more efficient and more effective. When the stabilizing front-liners can no longer support the leadership of a nation, chaos reigns – as we should understand from numerous current examples.

Our leaders are not listening to the upstreamer family physicians, teachers, public health, military, nurses, and front line public servants. Leaders need to listen to those who have the perspectives that can help to better understand normal Americans and those facing numerous dimensions of challenges. This perspective is often shaped because front liners tend to arise from lower and middle income and upper middle income Americans, rather than the top of the socioeconomic heap. Our top leaders, on the other hand, tend to come more from the exclusive sector, and such upbringing  makes it difficult to understand the daily lives of most Americans.

Falling Behind By Design

We are clearly falling behind as a nation. A greater proportion of or nation is falling behind in ways that make recovery more difficult. How we progress as a nation (or not) is about whether we can wake ourselves up to recognize the things that are required. Nations do not recover by economic development, defense, too much spending, or too little spending. Nations recover by investing in the earliest years of life. With progress made year to year or generation to generation, we can recover.

Few want to take responsibility for poor child well being, failures of investment in child development, numerous errors in the production and retention of important health care workforce, health costs that are too high for the outcomes, and other broken designs such as school funding mechanisms. It is easier to blame teachers or physicians rather than to make the investments that can make a difference. It is hard to see how these increasing costs and distractions prevent the investments that we need to make in our children – and our future.

Our education focus is downstream and works for those who do well without any intervention. Designs for school funding and standardized testing and high school and college focus do not work for most children left behind -- almost a tautology. Investments focused downstream insure that school districts in communities with high property values have good outcomes, those with middle property value less, and that even the high performing children from lower property value school districts do less well than those in the bottom portions of the higher property value school districts. Advantages for the advantaged also may retard the needed development of the advantaged children, because they are never challenged by the majority of the population who, if offered the same advantages and opportunity, might spur real competition that pushes all of them further ahead. The result is the lack of social class mobility that worsens in our nation.

How Do Declining Opportunities for Most Americans Shape Lack of Health Access?

Resolution of health access has two multiplier factors – origin shared with the population in need of health access and family medicine choice. Frankly, as Rabinowitz[1] has demonstrated, the effect of origin to help distribute physicians is negated when rural origin candidates do not choose family medicine. This is because their practice location is dictated by their specialty rather than their origin. FM choice facilitates the influence of origin. Social determinants can greatly limit access to medical school, but FM choice is 2 to 5 times as potent a marker for rural choice than medical school training and origins. Only FM physicians, and family NP and Pas, have population-based distribution – the opposite of all other specialties which are more concentrated where health care workforce is concentrated already.

Access to health care is mostly limited by lack of front line health access family medicine. We have insufficient MD, DO, NP, and PA family practice positions supported, offered, and filled.  This is the failed health policy determinant. It fails even more when “flexible” potential sources of family providers can easily choose other specialties; this is seen in NP and PA training programs, which are adding both more specialties and more trainees in each specialty, as well as internal medicine training for physicians.

What I have learned in two decades about family physician origins confirms social determinants and social situations that shape the proportion of providers in family medicine. The same social determinants shape medical school admission and performance as a medical student. After all, those who take -- and in particular do well on -- the tests are more likely to be highest income, most urban, and children of professionals. The standard population for scoring for tests such as MCAT and board exams are the subjects that take the test. Those students whose language, culture, parents, or other origin factors are different will have different scores. Normal origins are associated with different scores because they are normal. Exclusive origin students have exclusive scores. Scores shape opportunity, type of medical school, and even subspecialty. A normal distribution of career choice types is different because it is normal. Normal origins, normal types of medical schools, normal distributions of health spending, and normal career choices such as FM are the recovery vehicles for health access. This is not what our national design dictates. Origins, training, health spending, and career choices favor the concentrated or exclusive.

FM docs arise at 1 per 100,000 people across various types of counties or types of populations. In the populations associated with lower income and other social determinants that have lesser opportunity, about 4 per 100,000 are admitted to medical school per class year (1970 county pop, AMA Masterfile with 90% birth origins). This is 25% family medicine result. In the populations of advantage, about 14 - 20 per 100,000 per class year are admitted. These are areas around DC or NYC or other major metro areas with the highest income, most urban locations with top concentrations of professionals.  When you map concentrations of physician origins it is the same as where physicists, engineers, research and development, colleges, and other concentrations of professionals are found. In these areas most associated with concentrations or combinations of concentrations of high-income professionals, about 14–20 per 100,000 become a physician – about 2 to 3 times higher than average. However, for these populations associated with such concentrations, there is still only 1 per 100,000 found in family medicine per class year. Only 1 in 14 to 1 in 20 enter family medicine (about 5 – 7%). Moreoer, this was data from 20 years ago, at the peak of FM choice. FM choice in all types of origins has declined since this time.

Access is more than FM docs. When I look at rural docs or docs for underserved locations and map them to their birth county, the same 1 per 100,000 applies. Higher proportions of FM doctors arise from locations associated with lower concentrations of people. When there are higher concentrations, the proportions of rural or underserved docs decline. Meanwhile the most subspecialized docs most dense areas (metropolitan) with higher and higher concentrations from origins associated with higher concentrations. A doctor with a sub-specialty such as gastroenterology is 6-8 times more likely to come from a county in the top tier of population concentration as compared to those with lowest quartile income or population density.

Only FM has equitable population based origins and the same 1 per 100,000 per class year distribution, or about 30 FM docs per 100,000, for the current past 30 years of FM graduates. FM will actually decline slightly with population growth as FM is locked at 90,000 due to just 3000 annual graduates dating since 1980.

 

Declining Middle Class and FM

Populations vary in higher education and medical school admission. In the lower income segments, few arise for admission at all. Carnevale[2]and the Century Foundation have demonstrated that only 3% from the bottom quartile were found in the top 146 colleges – the same ones that feed the same types of students to medical schools. About 74% arose from the top income quartile. In the US middle income populations are disappearing, groups that used to be able to access higher education and they also had reasonable FM probability and distribution probability. The highest income segments are lowest FM probability. For example, at the University of Nebraska Medical School, those whose hometown is Omaha and Lincoln and other metro areas have 2% family medicine while those from the rest of the state have 15 - 30% FM choice (4 years of data). Out of state and foreign born components have been increasing and are typically highest income, most urban, children of professionals.

Asian Indian choice of FM was 2% for the 1990s - the population segment most representative of highest income, most urban, children of professionals in census and in AAMC data. All such populations are 3 - 10 times more likely to gain medical school admission in the US compared to the average. Advantages of child well being from the start of life are evident.

It is not about artificial markers of race or ethnicity - it is about highest income, most urban, highest property value, and other characteristics associated with advantage (or concentrations). Those more normal and representative are falling behind of all races and ethnicities. The same is true in studies of college students. Asian and white populations are populations of advantage and as Barr[3] demonstrated at Stanford, for students who planned to go to medical school when they were freshmen, these students of advantage had 100 – 110% actually apply to medical school, while the rate for underrepresented minorities, even in a select school such as Stanford, was only 50% remaining to apply for medical school. Advantage involves concentrations or combinations of concentrations as compared to normal. Those left behind are no small segment of the United States. Most Americans do not have the concentrations or combinations of concentrations needed for better opportunity, better cost of living, better health care quality, or easy health access.

Recovering Health Care Cost, Quality, and Access

The states doing best in health care quality consistently have the best child well being, the best markers of middle class, and the least divisions between rich and poor. Health care quality, access, and to some degree costs are related to child well being as expressed birth to admission in a student or as expressed birth until health care encounter in a patient. Downstream focus, and ever more dollars invested at the high school or college downstream level will not help. Research that attempts to claim better quality without changing Upstream tends to represent distractions from real improvements.

We have models such as Southcentral Foundation in Alaska and Grand Junction that illustrate what can be done - and these are just a start. These are models that recovered from poor designs to optimal designs. As a nation we can also recover from poor designs, by designing well from the earliest months and years of life. Who would deprive a 2 year old or a 3 year old of an opportunity to rise above?

We cannot do better as a nation with so many left behind from the earliest ages by design.

Health professionals such as family physicians can do Upstream work at the community level.

We need similar professionals working entire careers like we do to improve child development.

We need primary care and public health nurses that were trained specifically for primary care and public health - and who remain in such careers.

How we invest in our children and work locally in teams will determine our future.

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[1] Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. ”A program to increase the number of family physicians in rural and underserved areas: impact after 22 years.” JAMA. 1999 Jan 20;281(3):255-60.

[2] Anthony P. Carnevale and Stephen J. Rose, “Socio-economic Status, Race/Ethnicity, and Selective College

Admissions,” in Richard D. Kahlenberg, ed.,America’s Untapped Resource: Low-Income Students in Higher

Education. (New York: Century Foundation Press, 2004),

[3] Barr DA, Gonzalez ME, Wanat SF, “The leaky pipeline: factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students,” Acad Med. 2008 May;83(5):503-11. doi: 10.1097/ACM.0b013e31816bda16.

"Call the Midwife": If Britain could afford to create a National Health Service after WWII, we can now!

The main argument against not cutting (not to mention expanding) social services, including health care, for the most needy, is that we “cannot afford it”. This is the argument of the governors and legislatures in states that have refused to expand Medicaid, despite clear and convincing evidence that it will cost states much more to not do so (see Medicaid expansion will leave out many of the poorest: What is wrong with this picture?, May 26, 2013). This is portrayed in a very funny – except it’s really not -- “Daily Show” segment, cited by Dr. Allen Perkins in his blog, “Training Family Doctors”, Medicaid Expansion by the Numbers. Not being able to “afford” it is the mantra not only in the US, but also across Europe as those austerity hawks have been cutting off their people’s noses – and their election chances – in thrall to a false god.

So it was very interesting for me to watch the first episode of the British (BBC One) television series (now in its second season) “Call the Midwife”. Set in a poverty-stricken area of East London in 1957, midwives pedal their bicycles around the crowds of people and rubble that still covers the streets more than a decade after the end of World War II to attend to

pregnant women in their homes, delivering prenatal care and babies and even caring for the babies afterward. It is a not a beautiful scenario; the young midwife, Jenny Lee (based on the real life midwife Jennifer Worth, whose memoirs form the basis for the series and who died in 2011) has never seen such poverty, such crowding, such filth, so many children. It is the height of the “baby boom”, attributed initially to returning GIs who had to wait to start their families, but continuing with no end in sight; the women portrayed are having their fourth or fifth baby in their early 20s and many far more. In fact, of course, the end of this “boom” was not the aging out of the reproductive population but the introduction of effective and widely available contraception (especially birth control pills) in the 1960s.

The midwives, all nurses and many Anglican nuns, set up clinics in a gym in the interval between the pensioners’ breakfast and the evening dance classes, as well as attending women at home. They practice an obstetrics that is quaintly anachronistic, both in its tools (the wooden “fetoscope” to amplify the fetus’ heart sounds, and the glass rectal tube), and in practice (shaving the pubic area and administering enemas – “high, hot, and a helluva lot!”) but they provide much safer pregnancies and deliveries than had ever been available to this population in the past. At one point, a woman in her 23^rd (!!) pregnancy (already with 24 children, because of two sets of twins) goes into premature labor and the midwife is there to deliver what seems to be a stillbirth and begin care for the hemorrhaging mother while awaiting the arrival of the “obstetrics flying squad” with its ambulance, obstetrician, and pediatrician to continue to care, including blood transfusion in the home. When, miraculously, the baby comes to life, the mother refuses to send it to the hospital, feeding it milk with a dropper. The senior midwife tells Jenny that “we don’t ever care for these babies anymore; in the old days they died; now they go to the hospital.” When asked what they will do, she tells her they will visit three times a day until the baby is stable, and then at least once a day thereafter. In the home.

It is a dramatic and engaging story, but what fascinates me is that these services were available to these poor women. Home visits for prenatal care and delivery. Visits from nurses three times a day. An obstetrics “flying squad” to come to the homes of women who would otherwise die in childbirth. Where did the money for these services come from? Who paid these midwives, and these flying squad doctors? Well, the National Health Service (NHS). The NHS, established after the war, in 1948, to provide health care to all people in the UK. Not established at a time of prosperity, when we could “afford” it, but right after World War II, with both the nation’s economy and its literal infrastructure in shambles, with the piles of rubble still on the streets of London in 1957, 15 years after the Blitz. The National Health Service was not founded as a gesture of magnanimity from the wealthy, but as but as an explicit and well-thought out policy to provide one of the most basic of needs, health care, to all of the British people even though there was not much money; it was seen as a priority. In the second episode of "Call the Midwife", a woman who has lost 4 babies because of a pelvis contracted from rickets (vitamin D deficiency in childhood) is delivered of a healthy baby by Caesarean section. Rickets itself, the senior midwife says, is a disease of poverty and malnutrition eliminated by the NHS.

From the time I went to college and met upper-middle-class people, through my career as a doctor when I know lots of them, I have heard “horror stories” about the NHS, about the waits for things “we” never have to wait for, like elective surgeries. “My cousin says”, or “the people we had visiting from England told us”. But it was always apparent to me that this was a skewed group; the folks visiting from Britain on holiday were not the poor, were not the Welsh coalminers who had never had health care before. It is hard, I guess, when you have always been at the front of the queue, when the queue has always been so short for you that you didn’t even know there was one, to have to take your place in it; to wait in line with the hoi polloi. But ask those who never had had care, ask the poor, ask the women having babies in the Docklands.

My point here is not to romanticize poverty, or to suggest that things have always been perfect with the British NHS. It is, rather, to say that the provision of basic health care to all people is not and never has been a question of economics, it has always been a question of will. We can afford do it; indeed we cannot afford not to. Not only is it a “good investment”, it is essential humanity. Paul Krugman calls the group of health care expansion opponents “The Spite Club”, (June 7, 2013), arguing convincingly that their opposition is ideological, not fiscal. It is doubly sad to see this ideology acting in Europe, cutting the social safety net that has been in place there for decades.

When you think about what we can “afford” in health care, think about midwives making home visits to premature infants three times a day in the poorest areas of London in 1957. The expansion of Medicaid under the Affordable Care Act (Obamacare) may not be the best vehicle to bring care to the poorest (I still argue for a single-payer, Medicare-for-all, system), but opposing it is not fiscally responsible; it is both fiscally and morally reprehensible.

Helping primary care help the health of all of us

I recently described how primary care can improve the health of our population – proven by dozens of studies – as well as save significant money.  Recently, the distinguished family physician George Rust, MD, co-director of the National Center for Primary Care at Morehouse School of Medicine in Atlanta, made many of the same points in his testimony in front of the Senate HELP Committee’s Subcommittee on Primary Health and Aging (Dr. Rust is pictured here with Subcommittee Chair Sen. Bernie Sanders, I-VT). Rust specifically asked for significantly increased funding for Title VII and Title VIII, the sections of the Public Health Service law that provide grant funding for, respectively, primary care medicine and nursing programs, saying that they would represent "solid investments in the primary care workforce."

Rust also called for separating the funding for residency training provided by Medicare for primary care from hospital training of subspecialists, arguing that the current system has resulted in  "absurd proportions of subspecialists and hospitalists." I have often argued this (for example in GME funding must be targeted to Primary Care, December 10, 2011), noting that hospitals have an interest in training specialists and subspecialists who do things (usually procedures, given our current reimbursement system) that make money for hospitals, and much less for training the primary care doctors that are needed in the community. The problem is that, because academic medical centers provide a great deal of tertiary (and quarternary) care, the mix of primary care and subspecialist and super-subspecialists may be appropriate there, but not for the overall community. However, since these are the places where new physicians are minted and trained, providing the right mix for the community, for the rest of the state and country, means having a very different mix of specialists in training from those working there. This is hard; it is a very common reaction to want to replicate yourself, to want the “best” students to enter training in your specialty, so for an academic medical center which looks like the upside-down pyramid to train doctors in proportion to the right-side-up pyramid is a major challenge! Rust then suggests moving primary care training “back to its community roots”, and says "Instead, let's create direct, sustainable funding for community-based outpatient residency programs that train doctors to keep people out of the hospital”.

As strong as Dr. Rust’s arguments are, primary care will still have problems. One of the comments on the posting at the “AAFP News Brief” that covered this testimony  said “I must be missing something. Can anyone explain how creating more residency slots will increase med student interest in family medicine?” I believe that this is an excellent point – if we cannot fill the slots that exist today for family medicine, particularly with excellent medical students, how will increasing the number of slots improve things? One of the answers, certainly involves reimbursement, dramatically decreasing the difference between what primary care doctors earn and what more highly-paid subspecialists earn; work by the Altarum Institute cited by Jerry Kruse, MD MSPH in his article “Income Ratio and Medical Student Specialty Choice: The Primary Importance of the Ratio of Mean Primary Care Physician Income to Mean Consulting Specialist Income”, suggest that the ratio should be about 80%.

However, there are other factors at work. Sometimes they are referred to as “lifestyle” (perhaps defined as hours of work needed to generate a certain income, or what I have called the income/work hours ratio) but they are more profound than that. In the May/June issue of the Annals of Family Medicine, Christine Sinsky and her colleagues refer to it as “the joy of practice”. “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices” [1] identifies the “deep dissatisfaction” experienced by primary care physicians who care for adults (general internists and family physicians) demonstrated by the many reports of high “burnout” rates. The authors relate this to the extraordinary amount of time that physicians spend doing paperwork and administrative functions, and the pressure by employers to generate high numbers of visits; doctors experience this as alienating and not the reason that they became physicians.

“We propose joy in practice as a deliberately provocative concept to describe what we believe is missing in the physician experience of primary care. The concept of physician satisfaction suggests innovations that are limited to tweaking compensation or panel size. If, however, as the literature suggests, physicians seek out the arduous field of medicine, and primary care in particular, as a calling because of their desire to create healing relationships with patients, then interventions must go far deeper. Joy in practice implies a fundamental redesign of the medical encounter to restore the healing relationship of patients with their physicians and health care systems. Joy in practice includes a high level of physician work life satisfaction, a low level of burnout, and a feeling that medical practice is fulfilling.”

The authors go on to list a number of common problems, and solutions that have been found by one or more of the 23 practices that they visited and analyzed in detail. They included:

·       Reducing work through pre-visit planning and pre-appointment laboratory tests;

·        Adding capacity by sharing the care among the team;

·         Eliminating time-consuming documentation through in-visit scribing and assistant order entry;

·         Saving time by re-engineering prescription renewal work out of the practice;

·         Reducing unnecessary physician work through in-box management;

·         Improving team communication through co-location, huddles and team meetings;

·         Improving team functioning through systems planning and workflow mapping.

These are all good ideas, and the solutions are sometimes creative, sometimes painfully obvious, and sometimes obstructed by our bizarre health system. One of my favorites, the second, is an example of the latter:

“We observed that team development must often overcome an anti–team culture. Institutional policies (only the doctor can perform order entry), regulatory constraints (only the physician can sign paperwork for hearing aid batteries, meals delivery, or durable medical equipment), technology limitations (electronic health record work flows are designed around physician data entry), and payment policies that only reimburse physician activity constrain teams in their efforts to share the care. An extended care team of a social worker, nutritionist, and pharmacist may be affordable only in practices with external funding or global budgeting.”

Thus is illustrated the tie-in between innovations that can make practice again joyful and the payment reform and re-working of our entire non-system which we desperately need! There is a long way to go; as the authors point out, no single practice has solved every problem. But the linkage is clear – a medical care system designed to reward expensive interventions for a relatively small number of people has created an inappropriate mixture of physicians as well as an incentive for hospitals to focus mainly on such procedures, as it has increased the burden on, and in many cases taken the joy out of, being a primary care physician. It is important to remember that it is not just about the doctors (I try to remind my students and residents, precious as each of them are to themselves and their families and often to me, that ultimately it is not about them). The authors put it this way:

“The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training. Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks. Primary care physician burnout threatens the quality of patient care, access, and cost-containment within the US health care system.”

Both the macro-structural changes in the structure of the system as identified by Dr. Rust and the more micro-level changes in the practices of primary care clinicians identified by Dr. Sinsky and colleagues need to occur to make us have a sustainable, healthful, system of health care. And they need to happen soon.

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[1] Sinsky, C, et al.,, “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices”, Ann Fam Med May/June 2013 vol. 11 no. 3 272-278, doi: 10.1370/afm.1531  

Primary Care Contributes More than Money....

I have often written about why the US needs a comprehensive national health system to cover all of its people, and my preference for a single-payer system similar to that in place in Canada. I believe that this is necessary for our country to address its poor health statistics. You can’t have lots of people without financial access to health care and have a healthy country.  When financial obstacles exist, we have artificial and unnecessary suffering, pain, and death.

But having financial access to care is, although necessary, not sufficient. We need other changes in our health care system. For starters, we more primary care doctors and other providers, for another we need systems that encourage and reward quality of care, and we need to have everyone receive care that is need, no one receive care that is not needed, and have health, not profit, drive the system.

Unfortunately, this is not what we have. While a sensible health care system, such as that in most countries with better health outcomes than our own, is built on a broad base of primary care, with a much smaller number of subspecialists, and even less hospital (and even less tertiary care). Our system, or non-system as I have called it, is skewed toward high-technology, high intervention care, aimed at the top of the pyramid. Most of the resources are allocated there, and balanced on a relatively small number of primary care providers. As should be obvious, inverted pyramids are inherently unstable.

One reason for this inversion is the demand of people in the US, particularly those with good health insurance or lots of money, for more and more expensive, high-tech care. This follows from the general assumption that “if some is good, more is better”, and “if it costs more it must be better, and if it is better it is what I want” that pervades much of our culture. Unfortunately, those old saws are not true when it comes to health care. Frequently, less is better, and more is worse. This has increasingly been demonstrated with a number of ostensibly-preventive interventions that have been showed to both increase morbidity (because of false-positive tests that lead to dangerous but unnecessary intervention) and cost. These include PSA testing for prostate cancer (even the American Urological Association has come on board by not recommending this test for most men – AUA guidance cited in AAFP Smart Brief May 15, 2013; it should actually be for no men), mammography for breast cancer screening, and the never-had-any-justification-as-a-screening-test-in-asymptomatic-women pelvic exam (the part where the provider puts hands inside, as distinct from the Pap smear screening test for cancer of the cervix, Questioning the pelvic exam, by Jane Brody, New York Times, April 29, 2013).

Farther down the spectrum of health care interventions are the incredibly costly things we do to people at the end of their lives. Heroic things done that ultimately don’t make any positive difference, and often end up extending a poor quality of life, or have someone end their lives enduring continuous interventions, needle sticks, and harassment. Why do we do this? Maybe because we want it? Some of us do. A colleague relocated from Kansas to DC says that people in the East don’t seem to accept  that people die; she feels it is less of an issue in the Midwest, where farmers are used to animals dying, but I don’t know. I see it here. And, indeed, it is an extension of the observation by Marion Stone, the fictional hero of Abraham Verghese’s “Cutting for Stone”, that, in comparison to Ethiopia where he grew up and went to medical school, Americans seem to think of death as optional. But, of course, it is not.  Many Americans have come to realize that, and have advance directives limiting what is done to them. But some, or their families, keep bringing people whose bodies are trying to die, into the hospital where our interventional technology saves them – for the moment. Until the next admission, a month or a week or a day later. “We have created,” says an intensivist colleague, “a group of people who can only live in the ICU.”

But there is more. And that is that such high-tech, high-intervention, high-cost medicine makes money, for the doctors who do it and the hospitals that it takes place in. And, of course for the manufacturers of the devices that are used. This is why, in large part, we have a primary care/subspecialist imbalance, why the pyramid of health care is balanced on that knife-edge. If cardiac care makes the institution money, if cancer care or neurosurgery or orthopedics does, this is what those institutions want. These are the specialists that they will subsidize to be on their hospital staffs. These are the specialties in which teaching hospitals will voluntarily support residents and fellows, even if that creates an inappropriate mix of specialists for the community at large. I have often said that in medicine, unlike classical economics, supply drives demand as opposed to vice versa. But I have also said that, as insurers move to prospective payment, the former money-maker product lines become cost centers, and that primary care providers who can care for things themselves without lots of referrals will become profit centers.

There is already evidence that this financial situation is shifting. Health Leaders Media reports in a story by John Commins on May 20, 2013 that “A survey of hospital CFOs shows primary care physicians generated a combined average of $1,566,165 for their affiliated hospitals in the last year. Other specialties generated a combined annual average of $1,424,917, the lowest average in five years, data shows. Primary care physicians have emerged as key money makers for their affiliated hospitals and for the first time are generating more revenues on average than their specialist colleagues, a survey data from Merritt Hawkins (PDF) shows.” This has to be good for primary care doctors, and has to get the attention of both hospital administrators and subspecialists.

However, it may not necessarily be good for people’s health. I say this cautiously, because, as I think I have made clear above, I do not think that it is better to have more subspecialists doing more interventional procedures which do not improve the quality of life. But simply showing that primary care doctors generate more revenue for hospitals does not mean that things are that different; it may only mean that primary care doctors are referring more patients into hospitals for procedures. This is, in itself, not the goal.

There is a goal. The goal is improved health for the American (and all) people. The goal is everyone getting the care that they need that will benefit them, and no one getting care that will not benefit or might even harm them. The goal is the medical ethics principle of justice: that everyone has the same options for diagnosis and treatment open to them, based upon their disease and condition, and not their wealth. The goal is a society that provides the necessary basis for good health – food, housing, education.

We can achieve that goal. We have the resources. We just need the will.