This week medical schools including University of Utah and Tulane observe Primary Care Week, so we asked members of our community to reflect on this year’s theme, “primary care: the future of health care.” We’ll be posting their responses here throughout the month of October.
By John Geyman, M.D.
As is common knowledge, the U.S. health care system is beset by increasing problems of inadequate access, soaring costs that leave many millions of Americans without essential care, and variable and often-mediocre quality of care. Perverse financial incentives in a largely for-profit system drive provision of services by physicians, hospitals and other stakeholders in our market-based system that are inappropriate or unnecessary in almost one-third of instances. Among all of the advanced countries around the world, we have by far the most expensive health care, the least access and reliability, and the most inequity and disparities.
Added to these problems is the crisis in primary care itself. Specialization and subspecialization over the last five decades have reduced the primary care workforce in this country to a shadow of its former self. Rebuilding primary care as the foundation of our health care system is a key part of addressing our basic systemic problems. We have several decades of experience and numerous health policy studies that show us the following:
The more primary care physicians in an area, the better the access, coordination and outcomes of care.
The higher the ratio between primary care physicians and specialists, the lower the costs, number of hospital days and number of physicians seen by patients over a year.
Our multi-payer financing system, with 1,300 private insurers competing to cover the 80 percent of the population that uses the least health care is more profit-oriented than service-oriented; “denial management” and limiting their “medical-loss ratio,” not service, are the modus operandi.
Since fee-for-service reimbursement rewards procedures and highly specialized services over more time-consuming cognitive services typical of primary care, a large majority of each year’s graduates of U.S. medical schools opt for training and careers in non-primary care specialties. As a result, the nation faces a critical shortage of primary care physicians.
The politics of so-called “health care reform” have so far avoided the most fundamental questions concerning the future of health care, such as—should health care be a right or a privilege; should we have a system based on medical need vs. ability to pay; should our system be oriented to service (as has been the tradition among the health professions for many years) vs. profits on the supply side; and is health care just another commodity for sale on an open, deregulated market?
Primary care can, and should be, a main part of our approach to health care reform for this and future generations of Americans. But any incremental steps in that direction, including by the Affordable Care Act, will not get us there. Unless we rebuild primary care as the foundation of our system, we can expect increasing fragmentation and depersonalization of care with less access, coordination, and worse outcomes in an even more dysfunctional system than we have today.
We should strive for a generalist, primary care workforce that approaches a 50:50 balance between primary care and the other specialties. This will require us to address the basic questions raised above and to take a multi-faceted approach to reform that includes redesign of primary care practice, with increased emphasis on team care; changing how physicians are paid, with emphasis on salaried group practice; adopting single-payer national health insurance as the only way we will ever achieve universal access; and emphasizing evidence of efficacy and cost-effectiveness in coverage and reimbursement policies. Such an approach will probably require a couple of generations to achieve our goal of the best possible health care that we can afford for all Americans, so we should start now!
John Geyman, M.D., is Professor Emeritus of Family Medicine at the University of Washington School of Medicine in Seattle, where he served as Chairman of the Department of Family Medicine from 1976 to 1990. He was the founding editor of The Journal of Family Practice (1973 to 1990) and the editor of The Journal of the American Board of Family Practice (1990 to 2003). He has authored nine books on the health care industry including the 2011 Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans.