Newborns born in 29 other countries of the world have life expectancies exceeding 80 years; yet, an infant born in the US in 2016 is expected to live only 78.6 years according to recently released statistics. While death rates fell for 7 of the 10 biggest killers, such as cancer and heart disease, they climbed for the under-65 crowd. The irrefutable culprit is the unrelenting opioid epidemic.
Last year life expectancy declined for the first time since 1993. The last two-year decline was in 1962 and 1963, more than a half-century ago. I predicted (accurately) it would decline again this year unless there was a dramatic change in the primary care physician workforce. We are dying at a younger age today than two years ago– two months earlier to be exact. It might not sound monumental, but life expectancy is the king of noteworthy health statistics, making it quite significant in the grand scheme.
In the past, epidemics by definition were temporary; the narcotic epidemic will be anything but transient; there is no foreseeable end for the scourge of opioid addiction sweeping the nation. In my humble opinion, the solution to this dilemma is no different than it was last year, we must correct the primary care physician shortage. Time is of the essence. The last three-year decline occurred in 1912- 1914 as a result of the Spanish flu. Unfortunately, life expectancy will continue to decline until the nation makes comprehensive changes.
One in five Americans live in a primary care shortage area; the ratio of the population to primary care providers is greater than 2,000 to 1 (Bodenheimer & Pham, 2010), when it should be closer to 1,000 to 1. I am a third-generation primary care physician, with a unique historical perspective on how medical practice has changed since my grandfather made house calls back in 1940. My practice is currently located in a shortage area and the difference in volume compared to 16 years ago when I first hung a shingle, is extraordinary. Only 37% of doctors serve in primary care, yet 56% of the office visits are completed by that particular group of physicians (Health Resources and Services Administration, Bureau of Health Professions, 2008.) In my grandfathers’ time, primary care physicians made up 70-80% of the physician workforce.
Adding one primary care physician per 10,000 population, reduces mortality by 5.3%, avoiding 127,617 deaths annually. As an added bonus, primary care has a high rate of return on lives saved per dollar invested. Some healthcare policy experts believe the answer to the primary care physician shortage is to encourage physician extenders, such as nurse practitioners or physician assistants, to practice independently, a role for which their education was not originally intended. The misguided belief that the comprehensive education of a physician can be condensed into less than 5 years is preposterous.
The number of opioid prescriptions written in this country has doubled from 109 million in 1998 to over 200 million by 2011. As one example, studies show mid-level providers have markedly different prescribing practices when compared to their physician counterparts, a visit-by-visit comparison showed PA’s prescribe narcotics 19.5%, NP’s 12.4%, and physicians at 10.9% of visits overall. The differences between NP’s and physicians prescribing practices were most dramatic in rural areas, where the primary care physician shortage is most palpable. In the 2014 Drug Trend Report, NP’s and PA’s wrote 15.8% more opioid prescriptions for injured workers in 2013 than physicians.
Mid-level providers deliver high quality care in their role as physician extenders, however, if practicing independently right out of school, their fewer years of education reveal significant variations. Mid-levels report their patients are more satisfied when compared to patients with primary care physicians. Ironically, it is a well-established fact that the happier and more satisfied the patient, the more likely they are to die.
Life expectancy number will worsen in direct proportion to the primary care shortage. No one needs a crystal ball to predict the number and frequency of narcotics prescriptions will continue to increase nationwide when financial incentives emphasize the “satisfied” patient over one that is alive. A recent Huffington Post article lamented the fact the Canadian government ignored primary care physicians who predicted the impending physician shortage. “It’s precisely the front-line healthcare workers that know where the flaws and inefficiencies are. It’s time for governments to connect with them… to help fix the problems in healthcare.” Primary care physicians in the U.S. have been relegated to the back room. As a result, people are dying younger than before. One year ago, I asked whether declining life expectancy was just the tip of the iceberg, suggesting we should turn our attention to the dwindling supply of primary care physicians. What will it take for those in charge sit up and pay attention? How low will life expectancy have to go? Stay tuned…
Niran Al-Agba is a pediatrician practicing in Washington State.
If someone were contemplating an employed position with a large health care system or hospital based clinic, it seems unlikely they would choose primary care. If you want to increase the number of PCPs you have to start asking how all of your desired quality initiatives can be easily adopted by solo and small group PCPs. The initiatives would then of necessity have to be modified, something most in healthcare policy are reluctant to do. Take meaningful use, for example. It appears to me that nothing has been learned. Had you simply offered physicians and practices money with no strings other than to purchase a “certified” EHR then adoption rates would have been much higher. The lack of an apology from those who foisted that mess upon us PCPs is indicative of how much stock we should place in what they blithely moved onto next. The lack of applicability of current initiatives to solo and small group PCPs are in large part responsible for why I am no longer a PCP. Instead I work to reduce opioid use at a large FQHC and I treat addictions with medication combined with psychosocial support. With the lack of PCPs there is then a practical limit on how much effect increased numbers of PCPs could have on the opioid crisis. Instead of waiting for PCPs to materialize, we should be making it easier for the physicians who have expertise in treating addiction to implement evidence based treatment. Funding for what the physician does and for what the counselor does often come from different sources which makes implementing large scale treatment programs difficult. In my state medicaid excludes all but psychiatrists and “psychiatric NPs” from being credentialed, and thus treatment programs that are the beneficiary of grants and other funding cannot find prescribers to provide medication assisted treatment. The evidence from research supports combined prescriber/counselor programs, the funding does not.
I absolutely agree funding PCP’s who are already out there and have expertise treating opioid addiction is a brilliant way to go. Medicaid in our state drew a similar line in the sand regarding what we “can” or “cannot” prescribe based on our specialty. This is an arbitrary line and has resulted in less care for addiction, chronic pain, mental health disorders etc.. Thank you for your comments.
And, unbelievably, our primary care societies are working their butts off to make a career as a family physician, general internist, or pediatrician as unappealing as possible.
I used to think this was pure incompetence on their parts; now I’m not so sure . . .
This is absolutely true. See the recent letters in JAMA in which the ABIM and the entire ABMS member board structure received scathing repudiations in letters from Carlos J Cardenas, MD, President of the Texas Medial Association, and Bradley D. Freeman, MD from the Department of Surgery at Washington University School of St. Louis in Medicine. Will the governing boards listen? Of course not. They lie outside of medicine, accountable to no one. They deny board certification status while a high school student can become a “doctor” (DNP) by taking most of their courses online and bill themselves as whatever they want (“I work as a dermatologist, but I think I’ll be a neurologist today…”) and the hospitals and insurers credential them without batting an eyelash. Meanwhile physicians with decades of experience are being excluded because they chose not to play the game. It truly is a tragedy that is largely being ignored.
Drs. Whiting and Morgan – I completely agree that the specialty boards are a huge part of the problem. The best quote is “they lie outside of medicine, accountable to no one.” That is a huge part of the primary care physician shortage on top of everything else thrown our way.
Opioids are over-emphasized, they are a symptom as much as they are a disease.
But our struggling health care system has as much – if not ten times – as much to do with it.
Niran is spot on. Primaries are the front line on this one.
Think of them as cops on the street – or troops on the ground – if it helps
The opioid crisis appears to be just as bad in the cities and suburbs where there are plenty of primary care doctors and specialists. A New York City fireman tells me that he’s gone to the same house on four different occasions to revive the same person with Narcan.
We can have all the drug addiction treatment in the world but if the addict doesn’t want to fix his problem, treatment is likely to fail. Just being ordered into treatment by law enforcement or family members doesn’t solve the problem more often than not and it’s expensive to boot.
As for healthcare costs more generally, most of it is accounted for by people with chronic disease that needs to be managed plus surgical procedures and cancer treatment. There are plenty of doctors who order too many tests due to fear of litigation if they miss something and, sometimes, to drive revenue especially if they are employed by a hospital system. While NP’s and PA’s obviously have significantly less training than MD’s, I don’t think they’re a material part of our healthcare cost problem. Moreover, healthcare cost growth actually slowed significantly since 2010. Personally, I think forward 10 year estimates of healthcare cost growth by the CBO and others will prove to be significantly overstated.
Given the complexity and uncertainty in primary care, the best diagnosticians need to be at the front line. People without clinical skills order a CT for every headache, stress tests for every costochondritis and cultures for every little shit! Literally.
I have worked with excellent PAs and NPs, but Ibhave also seen what lies in the bottom of the barrel. At least with medical school credentials and 10,000 hours of evaluation and amangement experience, there is a t least a small chance of better diagnostic skills.
It is shocking sometimes those who have little in the way of clinical skills rack up the costs. I, too, have worked with top-notch mid-level providers and enjoy the collaboration, however the training is not equivalent and it never will be. It is not the way to repair the primary care shortage if we wish life expectancy to trend upward again.
Our nation’s return on investment (ROI) for education spending is 3:1, for early childhood education it is 7:1 and for anticipatory disaster mitigation it is 4:1. From a strictly actuarial standpoint, Primary Healthcare is highly unpredictable based on the usual underwriting rules. For adequate Primary Healthcare, its capitalization should be substantially increased with a continuation of a low level, fee-for-service revenue stream along with an age related, variably risk related, monthly capitation. With increasing PCP confidence in managing global risk, the capitation could be increased and stop-loss protected. In return, the hospital utilization would taper down by at least 30%. My group practice had a similar Gate-Keeper HMO contract for 13 years. We did not have any down-side risk experience throughout the contract.
Why not full capitation? After all, in my direct Care membership practice I do a lot of work that is not recognized by CPT; phone calls, care coordination, shopping for procedure and imaging discounts for cash patients, etc. Unleash innovation and hold physicians accountable by risk-adjusted downstream spending.
Our HMO practice was full capitation for primary healthcare, with 50% downside risk for the Hospital pool and also for the referral pool. The contract specified an 85% allocation to health spending by the plan. The risk pools were protected by $70,000 stop loss protection.
The clinical experience of most physicians, especially the medical school groups, doesn’t support the professional experience of most physicians that physicians can really control costs without jeopardizing their professional standards. Your observation is — spot-on!