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Help for Primary Care

By Dr. Sachin D. Shah
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I traveled last week to Washington, D.C., to meet with some members of Congress and their staffers, in an effort to help make the case for why Primary Care needs more support.  The day was organized by the Society for General Internal Medicine (SGIM), and I was joined in my meetings with our Illinois Senators and Representatives by fellow DFA member and Chicagoan, Ram Krishnamoorthi.

In meetings with the legislative affairs staff for Senators Richard Durbin and Mark Kirk and Representatives Judy Beggert and Danny Davis, we discussed why we thought Primary Care was so crucial to improving our health care system and how undervalued we felt as Primary Care Physicians despite that. 

The unfortunate but indisputable reality, of course, is that nothing substantial is going to happen in Congress in the coming months before the November election, especially regarding Health Care.  We acknowledge this sad testament to the polarized, dysfunctional nature of American politics today. 

We still went, however, to put a face on Primary Care, and in an effort to make a compelling argument for why we could play a huge role in improving the quality and reducing the cost of American health care.  Below are some of the points we tried to make.

Primary care physicians (PCPs) serve as the access point to the health care system for patients.  A good PCP guides patients through a convoluted, often confusing medical system, coordinates high quality care, manages multiple complex chronic diseases, and helps avoid complications that can result in costly, unnecessary ER visits and hospitalizations.  We help ensure our patients get the care they need and avoid care they don’t.  We work to earn our patients’ trust by establishing a relationship with them over time.  We answer their questions and address their concerns with the context to often be able to quickly detect concerning differences from their normal baseline. 

As generalists, we need to stay updated on the latest advances across a wide spectrum of medical information and help integrate that into our clinical practice to ensure our patients get the best care.  We scrutinize the medical literature to help determine whether a new therapy or intervention is actually better or simply a newer, more expensive alternative that offers no added benefits.

The Affordable Care Act (ACA), according to Congressional Budget Office estimates, will reduce the number of uninsured residents by 16 million by 2014 and 32 million by 2019. This will be a remarkable achievement, and an unequivocally positive step for access to health care for so many of our citizens.  Combine these projections with the 15 million baby boomers that will become Medicare eligible in this decade, and the need for Primary Care has never been higher.  And yet our primary care physician shortage is expected to reach 45,000 by 2020.

In reality, our health care system has been losing primary care physicians and infrastructure for years. The reasons are many, but include poor reimbursement rates, a significantly lower income for PCPs compared to their subspecialist colleagues, and a poorer quality of life because of increasing higher patient volumes and uncompensated after-hours work.

Although 56% of patient visits in the U.S. are primary care, only 37% of physicians practice primary care medicine, and only 8% of American medical school graduates go into primary care.  The shortage of primary care physicians across the U.S. undoubtedly contributes to more fragmented care, inappropriate use of specialists, and less emphasis to prevention.  Moreover, those Americans who are uninsured, low-income, and members of racial or ethnic minorities, or who who live in rural or inner-city areas are disproportionately likely to lack access to a PCP--and thus access to medical care.

Health care systems focused on primary care have been found to be associated with more effective, equitable, and efficient health services. Residents of countries like Canada and the UK, where there is an emphasis on primary care, often report better health outcomes at lower costs.

The current shortage of PCPs starts fundamentally with our current payment system, as compensation currently rewards procedures, tests, and imaging at much higher rates than counseling, coordination, or preventive measures. Quality of care is not valued nearly as much as quantity of care. As a result, there is a glaring incoming disparity between Primary Care Physicians and their subspecialist colleagues, which clearly influences career choices by medical students graduating with an average debt of over $100,000.  It’s no coincidence that the most prestigious, coveted, and competitive residency programs are in the highest earning subspecialties (Orthopedics, Radiology, Anesthesiology).

Patients with a regular source of primary care tend to use more preventive health care and have health problems treated at earlier stages. The decline in Primary Care has led to the overspecialization of medicine, with resulting fragmentation and inefficiency in the health system. Half of specialist visits today are for routine follow-up, which is an appalling misuse of expensive care.

We are not trying to pit Primary Care Physicians against Subspecialists.  These are our medical school and residency classmates and current colleagues on whom we rely tremendously.  We’re in fact confident our subspecialist colleagues would agree: we need more primary care physicians.

With the huge impending influx of new patients with access to medical care, there will be plenty of business to go around for both primary care physicians and our subspecialist colleagues, who provide remarkable, sophisticated, and life saving medical care to so many patients.  We simply want to eliminate unnecessary care and place a greater emphasis on prevention and quality of care, which we are confident will reduce wasteful spending and save our health care system an extraordinary amount of money.

We’re simply asking that our health care system place a greater value on Primary Care, a move that we passionately believe will improve the health of our patients, the quality of the care they receive, and the solvency of the health care system we all rely on.

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