Primary Care: A Miracle of Modern Medicine
What medical discovery touches everyone in the United States? What medical breakthrough is proven to reduce the galloping growth of health care spending? What medical wonder improves the quality of care for children and adults with many different illnesses? Share this brochure with others! Share your feedback with us! (see details, back cover) The John D. Stoeckle Center for Primary Care Innovation Massachusetts General Hospital Center for Excellence in Primary Care University of California, San Francisco
Primary care: The foundation of our health care system may be the greatest miracle of modern medicine!
What is primary care? When you hear people say, “I need to see my personal doctor,” or “My children’s pediatrician said they need to exercise more,” do you know what kind of doctor they are talking about? A primary care doctor! Patients and families can choose a family physician, general internist, pediatrician, or medicine-pediatrics doctor to be their primary care physician. Nurse practitioners and physician assistants work closely with these physicians to also deliver primary care. Primary care is the patient’s entry into the health care system and the medical “home” for ongoing, personalized care. Some people think that primary care physicians only handle simple things: making sure kids get their vaccinations, treating sore throats and bladder infections, and doing school and annual physicals. The truth is quite different. Primary care physicians need a vast amount of medical knowledge because they care for patients with hundreds of different problems including high blood pressure, elevated cholesterol, liver disease, back pain, memory loss, developmental and behavioral problems, depression, heart disease, asthma, obesity, and more. Primary care physicians also coordinate the care of their patients throughout the confusing health care system; for example, arranging for patients to get an MRI, choosing the right specialists, helping the elderly find their way through the pharmacy maze of Medicare Part D, and checking up on home nursing services. In addition, primary care physicians are a trusted source of information, helping their patients choose the best options and manage conflicting recommendations from specialists and other physicians.
The value of primary care A medical discovery that touches everyone in the United States • 94 percent of patients value having a primary care physician who knows about all their medical problems.1 • Primary care assists everyone who needs prevention services, help in managing chronic illness, and treatment of acute problems. That’s the entire population of the United States! A medical breakthrough proven to reduce the galloping growth of health care spending • Patients with a regular primary care physician have lower health care costs than those without.2-4 • When more primary care physicians, per person, are practicing in a community, hospitalization rates are lower.5 • States with more primary care physicians who care for patients on Medicare have lower Medicare costs; states with fewer of those primary care physicians have higher costs.6 A medical wonder that improves the quality of care for people with many different illnesses • Children and adults with primary care physicians are more likely to receive recommended preventive services, to have better management of chronic illnesses, and to be satisfied with their care.7-9 • States with more primary care physicians who care for Medicare patients have higher quality of care for Medicare patients; states with fewer of those primary care physicians have lower quality.6 • States with more primary care physicians per capita have lower total mortality rates, lower heart disease and cancer mortality rates, and higher life expectancy at birth compared with states having fewer primary care physicians, adjusting for other factors such as age and per capita income.10 2
Threats to primary care’s survival In 2006, the American College of Physicians, an organization representing both primary care physicians and specialists, warned that, “Primary care, the backbone of the nation’s health care system, is at grave risk of collapse….”11 That’s a strong statement, but it’s true. What are the facts? • From 1997 to 2005, the number of US medical school graduates entering family medicine residencies dropped by 50 percent.12 • In 1998, 54 percent of internal medicine residents planned careers in primary care rather than specialty medicine. By 2005, the number choosing primary care careers had dropped by more than 50 percent (see chart).13, 14
• The income of primary care physicians, adjusted for inflation, has dropped by 10.2 percent from 1995 to 2003,15 while the amount of work has increased. The combination of lower incomes and a stressful worklife discourages medical students and young physicians from choosing primary care careers. • Not only is the primary care physician pipeline drying up, but many primary care physicians are leaving their practices after only 15 or 20 years.16 • 42 percent of primary care physicians report not having enough time to spend with their patients.17 • The frustration of not having time for patients is made worse by a payment system that is unfair to primary care. For example, a specialist spending 30 minutes performing a surgical procedure, a diagnostic test like a colonoscopy, or an imaging study like an MRI, is often paid three times as much as a 30-minute primary care visit with a complicated patient who has diabetes, heart failure, headache, and high cholesterol.18 3
Investing in primary care Nations with strong primary care systems are supported by governments that make sure enough primary care physicians exist. As a result, they have lower health care expenditures.19 The United States needs a thoughtful national primary care policy. Leaders in Congress, the federal administration, state governments, and the private sector could help to improve health care quality, contain health care costs, and enhance patients’ health care experience by investing in primary care. Who needs to invest in primary care? To start with, the federal Medicare program does. Investing in primary care could reduce Medicare’s costs and help avert Medicare bankruptcy. Also, health insurance companies, whose rising costs are pricing employers and employees out of the health care market, could pay more to strengthen primary care. And finally, employers, who foot a large proportion of the health care bill, could save large sums of money by telling insurers to support primary care. Investing a greater proportion of health care dollars into primary care would be smart, since a strong primary care system translates into reduced use of high-cost services. What does it mean to invest in primary care? Fairer payment of primary care clinicians – physicians, nurse practitioners and physician assistants -- would attract more health professionals into primary care. If Medicare and health insurance companies paid primary care practices to hire additional staff – health educators, community health workers, and chronic care nurses -- practices could build teams to improve care, expanding the rushed 15-minute visit into a more satisfying experience for patients. Investing in primary care means paying for e-mail, telephone, and home visits for patients. It also means providing funds to help primary care practices obtain computerized medical records and create office systems that offer prompt appointments and longer team-based visits. Primary care practices that make these improvements are called Patient-Centered Medical Homes. 4
References Figure 1. Copyright © 2006 Massachusetts Medical Society. All rights reserved. Adapted with permission in 2007 from Bodenheimer, T. Primary Care – Will It Survive? N Engl J Med 2006;355:861-864. 1. Grumbach K, Selby JV, Damberg C, et al. Resolving the gatekeeper conundrum. JAMA 1999;282:261-266. 2. Weiss LJ, Blustein J. Faithful patients: The effect of long-term physician-patient relationships on the costs and use of health care by older Americans. Am J Public Health 1996;86:1742-1747. 3. De Maeseneer JM, De Prins L, Gosset H, Heyerick J. Provider continuity in family medicine: Does it make a difference for total health care costs? Ann Fam Med 2003;1:144-148. 4. Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care. JAMA 1992;267:1624-1630. 5. Parchman ML, Culler S. Primary care physicians and avoidable hospitalizations. J Fam Pract 1994;39:123-128. 6. Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs Web Exclusive, April 7, 2004;W4-184-197. 7. Bindman AB, Grumbach K, Osmond D, et al. Primary care and receipt of preventive services. J Gen Intern Med. 1996;11:269-276. 8. Safran DG, Taira GA, Rogers WH, et al. Linking primary care performance to outcomes of care. J Fam Pract 1998;47:213-220. 9. Stewart AL, Grumbach K, Osmond DH, et al. Primary care and patient perceptions of access to care. J Fam Pract 1997;44:177-185. 10. Starfield B. Primary care: Balancing health needs, services, and technology. New York: Oxford University Press, 1998. 11. The Impending Collapse of Primary Care Medicine and its Implications for the State of the Nation’s Health. Washington DC: American College of Physicians, January 30, 2006. 12. Pugno PA, Schmittling GT, Fetter GT, et al. Results of the 2005 national resident matching program: Family medicine. Fam Med. 2005;37:555-564. 13. Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med 2005;80:507-512. 14. West CP, Popkave C, Schultz HJ, et al. Changes in career decisions of internal medicine residents during training. Ann Intern Med 2006;145:774-779. 15. Tu HT, Ginsburg PB. Losing ground: Physician income, 1995-2003. Center for Studying Health System Change, Tracking Report No. 15, June 2006. 16. Sox HC. Leaving (internal) medicine. Ann Intern Med 2006;144:57-58. 17. Center for Studying Health System Change Physician Survey. http://CTSonline.s-3.com/psurvey.asp 18. Bodenheimer T. Primary care – Will it survive? N Engl J Med 2006;355:861-864. 19. Starfield B. Deconstructing primary care. In: Showstack J, Rothman AA, Hassmiller SB, eds. The Future of Primary Care. San Francisco: Jossey-Bass; 2004.
What Can You Do?
Revitalize Primary Care Bold initiatives are needed to revitalize primary care. While the Federal Government has a leading role to play, states, large employers, and health plans should also step up to the plate. The initiatives should address clinician payment, practice infrastructure, and the training pipeline. Much can be implemented in a budget neutral fashion since revitalized primary care can reduce hospital and specialty costs. Other elements require relatively small amounts of new investment.
A primary care revitalization agenda: • Amend the Medicare payment structure to provide sustained increases in primary care clinician reimbursement, as recommended by the Medicare Payment Advisory Commission (MedPAC) in its June 2008 report to Congress. This is an essential first step to reverse the growing primary care shortage. • Support primary care practices in transforming themselves into Patient-Centered Medical Homes by providing financial incentives through increased Medicare, Medicaid and private insurance payments. • Create regional primary care cooperatives with experts to offer technical support to primary care practices, assisting them to become Patient-Centered Medical Homes and to adopt health information technology. • Develop loan forgiveness programs for health professional students choosing primary care careers, and add incentives for clinicians choosing to provide primary care to underserved populations. • Reform the Medicare Graduate Medical Education system so that Medicare educational dollars are prioritized for residency training in primary care. Increase funding for Title 7 primary care physician training.
If you are an employer paying for the health care of your employees, or if you work in Congress, the federal Department of Health and Human Services, state government, or a private health plan, please advocate for the agenda described on the previous page. If you work in primary care, please send copies of this brochure to your Congressional and state legislators with a cover note asking them to actively promote this agenda.
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Department of Family and Community Medicine University of California, San Francisco [email protected]
The John D. Stoeckle Center for Primary Care Innovation Massachusetts General Hospital Boston, MA 02114 [email protected]
© 2009 Massachusetts General Hospital 3/2009 (3rd Edition)