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In a much needed and straightforward article published in the August 31 issue of The New England Journal of Medicine, Thomas Bodenheimer, MD, MPH, professor of family and community medicine at UCSF outlines the crisis in primary care medicine that could threaten the health of millions of Americans.
While the article makes a clear and welcome call to action, “Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.”. One shortcoming of the article, directed at the medical community, is that Dr Bodenheimer fails to clearly include any “alternative” health professionals or treatments in his solutions. Today alternatives to standard drug and surgery based medicine are a staple of health care for millions of Americans.
“A strong primary-care base for a health system improves care and reduces health care costs,” says Bodenheimer.
Lack of New Family Doctors
“The number of US medical graduates choosing careers in family medicine has fallen by 50 percent since 1997,” Bodenheimer says. “In addition, only about one-fifth of US medical graduates entering the field of internal medicine pick careers in primary care medicine; most pursue specialized training in gastroenterology, cardiology, and other specialties.”
Bodenheimer cites three main contributing to the demise of primary care:
- Low reimbursement rates for primary care services
- The stressful work life of primary care physicians
- These two problems are resulting in a dwindling number of US medical graduates choosing careers in family medicine
Patient and Doctor Dissatisfaction Growing
The prevalence of chronic conditions– most of which are handled in primary care settings– is increasing along with demands placed on physicians to perform primary care tasks reliably and consistently. According to research cited in the article, a physician with a typical number of patients would take 10.6 hours per working day to offer all recommended chronic care, plus an additional 7.4 hours per day to provide routine preventive care, clearly an impossible task, according to Bodenheimer.
Patients and doctors are increasing frustrated with the current primary care system, Dr Bodenheimer says in his article, “The great majority of patients prefer to seek initial care from a primary care physician rather than a specialist, but their unhappiness with their primary care experience is growing. At the same time, primary care physicians are expressing frustration that the knowledge and skills they are expected to master exceed the limits of human capability, making it impossible to provide the best care to every patient.
“As the number of primary care physicians dwindles, patients are having a harder time getting timely appointments with their personal physicians,” says Bodenheimer. “Many patients seek expensive emergency room services because they are unable to obtain appointments with their personal primary care physician, adding to the cost and failure of the system.”
Action Needed to Save Cost Effective Primary Care
Bodenheimer urges action to stop the demise of primary care in the form of an educational campaign to explain the nature and causes of the threats to primary care’s survival, to provide well-documented information on the benefits of primary care, and to offer concrete proposals for reforming the current broken system.
“Averting the collapse of primary care requires reform in the payment system and improvements within primary care practices,” says Bodenheimer. “It also requires a coordinated effort between employers and insurers, health care providers and patients, public and private institutions, and government.”
A bolstered, more effective primary care sector would reap a return on investment by employers and insurance companies as well as benefit the public through a reduction in health care costs nationwide, he argues. “Unfortunately, to date, public policy on primary care is nearly nonexistent, leaving the fortunes of primary care dictated not by the health care needs of the country, but by a specialty-rich, quantity-based reimbursement system,” he says.
Bodenheimer also makes the argument that patients with a regular primary care physician have lower overall health costs than those without. And compared with specialists, primary care physicians provide comparable quality of care at lower cost for a variety of conditions such as diabetes, hypertension and chronic lower back pain. “Primary care is a resource the American public can not afford to lose,” he adds. “Health care systems need a strong primary care base in order to ensure the provision of preventive and chronic care services to patients, and in order to keep healthcare costs under control.”
