By KEN TERRY
(This is the fourth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)
Many other countries’ healthcare systems outperform ours for one simple reason: They place a much greater emphasis on primary care, which occupies the central place in their systems. “The evidence is that where you have more primary care physicians, where you coordinate care, and where you pay to keep people healthy, you get better outcomes at lower cost,” says David Nash, MD, founding dean of the College of Population Health, part of Thomas Jefferson University in Philadelphia.
The evidence that Nash mentions includes studies by Barbara Starfield and her colleagues at Johns Hopkins University. In a 2005 Health Affairs paper, they showed that a higher ratio of primary care physicians to the population is associated with a lower mortality rate from all causes and from heart disease and cancer; in contrast, having more specialists in a particular area does not decrease the overall mortality rate or deaths from cancer and heart disease.
Another study of Medicare data found that states where a higher percentage of physicians were PCPs had higher quality care and lower cost per beneficiary. This factor alone accounted for nearly half of the variation in Medicare spending from one state to another. A separate study found that in the areas of the country that had the most primary care providers, the average Medicare cost per beneficiary was a third lower than in areas with the least PCPs.
One reason for this is that primary care doctors provide comprehensive, continuous care, including preventive and routine chronic care. Chronic illnesses drive 90% of health costs, and some studies show that intensive primary care can reduce ER visits and hospital admissions and improve the health of chronically ill people.
In addition, primary care physicians strive to understand the whole patient, both physically and mentally. Besides having an in-depth knowledge of each patient’s health factors, “I know what’s going on in their lives,” says Jeff Kagan, MD, a Connecticut internist. “I know who’s getting divorced and who’s lost their job and who has some stress in their life.”
This comprehensiveness is an essential feature of primary care. “We don’t miss an opportunity to fix the things that down the road are going to be significantly greater problems for you,” says Russell Kohl, MD, an official of the American Academy of Family Physicians (AAFP). “That’s the challenge we have around a specialty-driven approach, where patients say, ‘let me see a bone doctor for my bone problem or a heart doctor for my heart problem, or a kidney doctor for my kidney problem,’ and not see those three things are integrally connected with each other. It’s that comprehensive approach that makes sense for you long term.”
A “Sick” System
Not all primary care physicians provide this level of holistic care. But in general, primary care is oriented to keeping people healthy as well as treating them when they’re sick. And primary care is “upstream” of the more costly, specialized care that may be required when people get really ill.
Overall, Nash notes, the U.S. healthcare system is designed to treat sickness, not to maintain health. “If we had a focus on going upstream and shutting off the faucet rather than mopping up the floor, primary care would have a central role,” he says. “But the system is focused all downstream, which reduces the prestige of primary care physicians and the range of skills that they need. If the system were focused upstream, they’d be paramount.”
The difference in how primary care physicians are regarded in the United States and in other nations is reflected in the amount of resources devoted to them. In this country, one study finds, only 7% of the total cost of care goes to primary care (other studies estimate it at 5%). In contrast, around 20% of healthcare spending in other advanced countries is allocated to primary care. The ratio of specialists to primary care doctors in the United States is about 2:1. In other countries, the ratio is about 50/50.
Since these other nations rely much more heavily on primary care than we do, their systems are organized differently from ours. So, if we want to achieve results similar to theirs, we should restructure our system to emphasize primary care. However, the indicators for U.S. primary care are moving in the opposite direction.
Shortage of primary care
We have a worsening shortage of primary care. In 2010, there were 246,000 primary care physicians in the U.S., of whom 208,800 were practicing full time.No comparable figures are available for 2020; however, from 2005 to 2015, one study found, the number of jobs for primary care doctors grew by 8%, while the number of jobs for specialists grew six times faster. At the same time, the share of the physician workforce devoted to primary care decreased from 44% to 37%, while the number of primary care doctors per capita remained flat.8
A portion of the demand for primary care is being met by non-physician clinicians such as nurse practitioners (NPs) and physician assistant (PAs). When these clinicians were included in the total, the study noted, the supply of generalist providers grew 17% between 2005 and 2015. However, this was still much less than the growth in the specialist workforce, and midlevel practitioners cannot do as much as primary care doctors can.
A wide range of experts agree that there is a primary care shortage. Nash sees this shortfall as the main reason the business of retail clinics and urgent care centers is booming. Travis Singleton, the executive president of physician search firm Merritt Hawkins, describes the current situation as “the worst primary care shortage we’ve had in 20 years.”
And things are expected to get even worse. Only 20% of young doctors are going into primary care, and the percentage of PCPs in the physician workforce has fallen to 32%. By 2030, forecasts the Association of American Medical Colleges (AAMC), there will be a shortfall of between 14,800 and 49,300 primary care doctors. The AAMC also predicts a shortage in non-primary care specialties of between 33,800 and 72,700 physicians.
To some extent, Nash notes, the shortages may reflect the maldistribution of U.S. physicians, who are concentrated in major urban centers. The PCP-to-population ratio in rural areas is only 39.8 per 100,000 people, compared to 53.3 in urban areas, according to the Centers for Medicare and Medicaid Services (CMS).
Practice management consultant David Zetter points out, however, there would still be a primary care shortage even if PCPs were better distributed. “Take Houston,” he says. “It’s classified as a physician shortage area, although it’s a very large metro area. A lot of primary care doctors are booked up there, and they’re not taking new patients.”
So, if we want to refocus our healthcare system on primary care, we’ll have to increase the number of primary care physicians across the country. Thus the restructuring of the system must provide incentives for more doctors to go into primary care.
Ken Terry is a journalist and author who has covered health care for more than 25 years.