The survival and character of primary care in the United States

Citation

Smith, W.R. (2009), "The survival and character of primary care in the United States", Clinical Governance: An International Journal, Vol. 14 No. 1. https://doi.org/10.1108/cgij.2009.24814aaf.001

The survival and character of primary care in the United States

Article Type: North American perspectives From: Clinical Governance: An International Journal, Volume 14, Issue 1

Introduction

“With liberty and justice for all”[1]. “… that they are endowed with certain inalienable rights, among them life liberty, and the pursuit of happiness …”[2]. These words support the prevailing belief in the USA that health care is a right, not a privilege. Yet, high-quality care for US residents is at increasing risk of becoming a privilege, not a right, and certainly not a guarantee. Of late, the crisis scenario of failed access to high quality care not only includes the usual financial barriers, mal-distribution of resources, or failures and errors in health care systems and individuals, but also includes mounting workforce barriers, all with no solution in sight. Put simply, the news is that the USA now faces an emerging, critical shortage of primary care physician specialists, defined as family medicine, general internal medicine, and general paediatric specialists, trained in either osteopathic or allopathic medical schools. The view is that the projected shortage of US primary care physicians could exceed 40,000 by 2025 (Colwill et al., 2008).

This critical workforce shortage is already creating a vacuum in the central core of the health care system. The shortage of primary care for US residents, along with other well-characterized problems of the US health care system, threatens to violate the country’s very core values, as well as the health of its citizens. Meanwhile, instead of moving towards filling this vacuum, the country appears to be moving towards worsening it.

Two sets of opposing, exacerbating and relieving forces are at war at the center of the crisis. The degree to which high quality primary care will be available to all is dependent on which set of forces ultimately wins.

Reduction of primary care physician supply

Primary care has been defined as “a span or an assembly of first-contact health care services directly accessible to the public” (World Health Organization Europe, 2002). Important characteristics of good primary care include first-contact accessibility, longitudinality, communication, coordination, comprehensiveness, and cultural appropriateness. Clearly physicians and direct care clinicians are one of the most important components of primary care. But a system of care and supporting resources must underlie and enable this human interface. Given this system requirement, perhaps the strongest force creating the vacuum of primary care is the deteriorating structure and function of the US health care system itself.

Report after report document the US health care system is strained and nearing collapse (Sandy, 2002). The US health care system continues to try to care for 15.3 per cent of the population, 45.7 million people, who are without health insurance. Further, it cares for residents living in a country where income inequality continues unabated, and income is strongly related to health. From 1997 to 2005, the Gini index has held steady at 0.46 to 0.47. It ranges from 0, indicating perfect equality (where everyone receives an equal share), to 1, perfect inequality (where all the income is received by only one person or group of people) (DeMuro, 1994). Meanwhile, US health care is becoming increasingly expensive. In 2006, US health care costed $7,026 per person, or 16 per cent of the nation’s gross domestic product (GDP), the largest proportion in the world (Catlin et al., 2008). Together, these forces are making health care unavailable or increasingly unaffordable for a large number of working and non-working Americans.

Not surprisingly, racial, social, and ethnic health and health care disparities dominate the US health care landscape (Smith, 2007; Smith et al., 2007). Also not surprisingly, front-line battles are emerging between patients and their primary care physicians, as patients advocate for the care they feel entitled to, and primary care physicians face increasing managed care restrictions to offering that care (Grumbach et al., 1999).

US health care providers are flailing under the environmental stresses of this broken system. For example, over the 1990s, the number of students entering nursing school declined by 25 per cent (O’Shea, 2001) and the age of the average nurse increased from 37.7 to 45.2 years (General Accounting Office, 2001). Now, the workforce supply problem has spread to physicians, and in particular, primary care physicians. General internal medicine is in particular trouble (American College of Physicians, 2008). Approximately 21 per cent of physicians who were board certified in the early 1990s have left general internal medicine, compared to a 5 per cent departure rate for internal medicine sub-specialists (Lipner et al., 2005). Simultaneously, there has been a precipitous decline in the percentage of internal medicine residents who opt for careers in office based general internal medicine versus subspecialty or hospitalist medicine (Bodenheimer, 2006). The other primary care specialties are also in danger (Kuehn, 2008).

Why the exodus from primary care specialties? Some blame the failures of the specialties themselves, citing disorganization and lack of attractiveness of training programs for medical students in the throes of making a specialty choice. They suggest redesigning clerkships so they do not discourage students from pursuing residency training in a primary care specialty. They urge establishing contemporary models of chronic-disease management, in which teams of health care professionals are guided by the principles of patient-centered care and are supported by the information-technology systems needed to provide high-quality ambulatory care (Whitcomb and Cohen, 2004)).

Medical students in 2008 provided some fodder for this contention. Among those surveyed about their recently-completed specialty choices, only 2 per cent of graduating medical students planned to pursue a career in general internal medicine, compared to 9 per cent 18 years ago. Only about 20 per cent cited that their core internal medicine clerkship made a career in general internal medicine seem more attractive, whereas about 50 per cent responded that it made a career in subspecialty internal medicine more attractive (Hauer et al., 2008).

But the exodus cannot only be blamed on failings of the training and exposure of medical students and residents. In the same study, students reported that, in addition to clerkship experiences, two other factors influenced career choice regarding internal medicine: the nature of patient care in internal medicine, and lifestyle. Clearly, the practice environment, lifestyle and salary offered to primary care physicians does not rival that offered to practitioners of more glamorous specialties such as radiology, ophthalmology, dermatology, orthopedics, and even pathology. It appears that, ironically, circumstances of the overall health care crisis are pushing medical students away from becoming part of the solution to the health care crisis.

Other studies corroborate the importance of role models (Campos-Outcalt and Senf, 1999; Elnicki et al., 1999; Mengel and Davis, 1995; Gazewood et al., 2002) and curriculum (Bland et al., 1995; Meurer, 1995; Morrison and Murray, 1996) for attracting students into primary care, and corroborate the importance of mounting student debt and the circumstances and work conditions of the primary care environment on dissuading students from primary care (Schwartz et al., 1991; Rosenthal et al., 1994). Clearly, in the last few years the financial forces on students entering medical school in the USA have changed. The debt burden to these students is far higher now. From 1999 to 2004 total educational debt to graduating medical students increased by 23.01 per cent, thwarting many students’ noble impulses toward primary care, while the Consumer Price Index increased by only 9.24 per cent (Rosenblatt and Andrilla, 2005).

Filling the vacuum of primary care

The primary care vacuum will undoubtedly leave many US residents with unmet health care needs. However, other residents with the necessary financial resources will undoubtedly take steps to fill their personal primary care vacuum. Further, if the feared collapse of the health care system occurs, other parts of the dysfunctional system may attempt to fill the primary care vacuum inappropriately. Emergency departments may become even more backlogged (Trzeciak and Rivers, 2003). More detached urgent care centers may spring up, staffed by unsupervised mid-level providers using care protocols. Mid-level providers may also partner with sub-specialist physicians, attempting to provide primary care in these physician’s offices, and referring only the “interesting” or “complicated” cases to the physician.

Among physicians who still choose or still remain in the specialties of primary care, more may become so-called “boutique” or “concierge” physicians (Kirkpatrick, 2002; Reinhardt, 2002). Already, physicians delivering this style of care are in such high demand that they can require a substantial cash “retainer” payment from their monied, upper-class clients seeking to assure their own primary care services. While this model fulfills the personal needs of its clients and the practitioners who choose it (Matus, 2003), it does not provide a system of care for a population, and will ultimately fail the country (Goodson, 2003; Charatan, 2002).

A disturbing trend from the global perspective is that the US is effectively robbing graduates of foreign medical schools from the poorest and most deprived countries to maintain its primary care physician supply, while US graduates and foreign graduates in the US from more affluent countries drift to specialty care (Starfield and Fryer, 2007).

Current political battles over health care in the USA seem focused on payment reform, not on delivery reform, and certainly not on the shortage of primary care. The climate seems so far removed from the managed care, vertically integrated delivery system mandate surrounding the massive, failed attempt at US health care reform in 1994 (DeMuro, 1994; Johnson and Broder, 1997). Health care reform was one of the Clinton Administration’s highest priorities. In preparation for Clinton health care reform and after the invasion of managed care financing, the US quickly began trying to retool and increase the supply of primary care physicians, but this effort fizzled along with both reform and the primacy of managed care (Marcille, 1994; Starfield, 1997). Now some 14 years later, even with a system bordering on collapse, a similar lack of inertia for change in primary care delivery seems evident in public debate and political discourse (McInturff and Weigel, 2008). Both major parties’ 2008 presidential platforms prominently discussed “health care reform,” but did not address supply of physicians, specifically supply of primary care physicians, preferring instead to talk about preventive care maintenance to save money (Cohen et al., 2008), or payment reform and disease/care management (Marsh, 2008).

Though the Clinton policy did address supply, organization of care, and quality of care, it was soundly defeated in Congress. Some say the Clinton health care reform policy failed because the public was either insufficiently dissatisfied with the current system, or unwilling to pay for a better one (Skocpol, 1997). Others say the good in the proposal was drowned in a torrent of bureaucracy that would have been unwieldy and inefficient to administer. Still others say that both then and now, there was (and still is) a lack of political will to confront major players in medical care funding, especially the insurance companies and large employers (Navarro, 2008). Both are huge political donors, and both stand to lose a lot if health care reform does not favor their interests.

Reorganization and resurgence of primary care: a hopeful scenario

Hope for primary care hinges on a second set of forces arising out of the health care community which aim to appropriately fill the vacuum of available primary care. Thoughtful members of the health care delivery system are proposing and testing new models of primary care, rather than endlessly studying the current primary care system, rediscovering its problems, and reporting on its demise. Several new models have been proposed and are in various stages of implementation and testing. Perhaps the overarching component linking these models, one that sometimes has been missing in the old models, is the concept of physician-led team care. Another very important but previously missing component is excellent information management and communication.

Currently, the most visible of the new approaches to primary care is the Patient-Centered Medical Home. Emerging from pediatrics (American Academy of Pediatrics Medical Home Initiatives for Children With Special Needs Project Advisory Committee, 2004; Turchi et al., 2007; Stille and Antonelli, 2004), but later adopted by both internal medicine (American College of Physicians, 2006) and family medicine specialty societies (Kruse, 2007; Kellerman and Kirk, 2007; Future of Family Medicine Project Leadership Committee, 2004), the Medical Home is both a primary care concept and a service intended for reimbursement by payors (Schoenbaum, 2007; Antonelli and Antonelli, 2004). It hearkens back to earlier concepts such as community-oriented primary care (White et al., 1961; Gavagan, 2008), promoted and supported by the US Health Resources and Services Administration, which emphasizes defining a target community and its collective needs, then building a primary care training and delivery system best suited to meeting those needs (Strelnick et al., 2008; Lipkin et al., 2008; Reynolds, 2008). It builds on the concepts of prevention and coordination of care embodied in the original health maintenance organization movement (Mitka, 1998; Mayer and Mayer, 1985). It embraces the principles of the Chronic Care Model (Wagner et al., 2001), which espouses and explains a structure for continuity of care and strong primary care. The Medical Home also incorporates principles of case management, “a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes”[3,4].

The Medical Home promotes primary care physicians as appropriate leaders of teams designed to implement high quality, holistic primary care. It suggests components of the team, as well as resources, such as a lifetime portable medical record, required to implement good primary care (Blue Ribbon Panel of the Society of General Internal Medicine (2007), even to the point of describing the anatomy and physiology of team visits and between-visit care (Bodenheimer and Laing, 2007).

While evaluations of the Medical Home are just emerging (Antonelli et al., 2008), learning collaboratives have had time to innovate and reorganize primary care practices – particularly in community health centers, integrated delivery systems, and academic medical centers – to implement components of the Chronic Care Model. Reports are emerging showing improvements in process and outcomes (Vargas et al., 2007).

Physician-led, team-based primary care should be a potential win for providers, patients, and payors. Primary care providers should be interested in a model of primary care that improves their salaries, work environment, and lifestyle. Perhaps learning from the popularity of both boutique and subspecialty medicine, they likely want a practice style that makes more efficient use of their intense training, which often focuses on sophisticated or complex care management, rather than on routine management, case management, or patient education. Nonetheless, they likely are aware of how important patient education, case management, and communication are, and how much can be gained (both physician satisfaction, patient satisfaction, and improved adherence) from personal face-to-face and between-visit time spent communicating with patients. They likely want the ability to deliver these services directly, or to supervise their delivery when appropriate.

Patients (or their surrogates, employers) should become attracted to team-based primary care. They may perceive it will improve the quality of ambulatory care visits, and their satisfaction with these visits, by letting their specific needs for the visit be known, then met. They may hope the improved communication will increase their ability to navigate the complex health care system. Employers may hope this model provides a central point of contact, of information storage and retrieval, and of coordination of care that will reduce out-of-work time due to inadequate education, communication, or errors.

Payors, especially state and federal governments, are interested in better value for the dollars they supply for primary care. A recent study supports the value proposition of primary care, concluding that an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3 per cent, or 49 per 100,000 per year (Macinko et al., 2007). Already, the federal government, in the form of the Centers for Medicare and Medicaid Services, is experimenting with differentially higher payment for practices providing better quality of care measures (pay-for-performance) (Greene and Nash, 2008; Shaman, 2008). As long as quality of care measures justify the costs (Robeznieks, 2007; Starfield, 2008; Starfield and Shi, 2007), CMS may be willing to pay primary care teams for implementing a medical home for targeted groups of patients, even those with multi-system chronic organ failure, economic hardships, or other risk factors which in the past have made primary care practice difficult, unprofitable, or unattractive (Barr, 2008; Files et al., 2008).

Critics might describe these movements and concepts as merely the latest idealistic but doomed attempt to make primary health care a right and not a privilege. However, it is easy to conceive that a redesigned primary care system (Lee et al., 2008) which adequately compensates its team members, improves patient care quality, and better satisfies patient, physician, and payor needs, would attract all three groups to its door. It would reinvigorate primary care physician supply by removing barriers to entry into the workforce. The only salvation for primary care is that the invigorating forces, the innovative ideals for primary care will win out over the forces reducing primary care availability to the US masses.

With the election of Barack Obama as US president, many Americans are likely hopeful that, as a reputed quick study, he will quickly discover that financing solutions to ensure access to care will ultimately depend on a health care workforce that is adequate and accessible. Any package to reform health care should include a stimulus to produce more and better qualified primary care physicians, and to support the army of people and resources necessary to provide primary care.

From the Pledge of Allegiance to the United States Flag.

From the Preamble to the US Declaration of Independence.

Case management. (2008, August 19). In Wikipedia, The Free Encyclopedia, available at: http://en.wikipedia.org/w/index.php?title=Case_management&oldid=232807860 (accessed 19 August, 2008)

Case Management Society of America, “Definition of Case Management” available at: www.cmsa.org/Consumer/GlossaryFAQs/tabid/102/Default.aspx#c (accessed 13 January 2007)

Wally R. SmithDivision of Quality Health Care, Virginia Commonwealth University, Richmond, Virginia, USA