What about primary care?
“Uncomplicated” Primary Care?
By Josh Freeman
Medicine and Social Justice
October 8, 2009
I have often written about the importance of primary care, the shortage of primary care physicians, and the fact that fewer medical students are choosing primary care careers, which will exacerbate the problem. A key part of this analysis is the large number of studies, by researchers from a variety of settings, that show that the presence of a higher proportion of primary care doctors decreases cost and increases quality.
However, not everybody agrees. In an earlier post, More Primary Care Doctors or Just More Doctors?, I discussed the position taken by Dr. Richard Cooper, former Executive Vice President and Dean of the Medical College of Wisconsin and currently Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, who argues against this position.
Dr. Cooper and a group of equally distinguished colleagues restate this position; in particular that the value of primary care is overstated. In an excerpt from (their Physicians Foundation report) they note:
“Primary care has been a central focus of health care reform. In modeling the future workforce, the Project Team acknowledged the critical importance of primary care services and the role of generalist physicians in providing them. However, the Team rejected the claim by Starfield and others of lower mortality in regions with more family practitioners as a statistical anomaly, and it questioned the wisdom of deploying generalist physicians to take responsibility for the proposed medical homes. Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care.”
The American Academy of Family Physicians (AAFP) in its formal response to the Physicians Foundation report includes the following:
“This study is largely a recapitulation of the primary author’s paper in Health Affairs in January of this year. In that same issue, several researchers pointed out the fundamental flaws in this simplistic research showing that important basic adjustments showed this work to strongly support the prior studies it criticized. It continues to claim that population differences explain past findings for the value of primary care and variance in spending, when these were fully accounted for in these studies. This report does not repair those flaws. It labels several well-validated and valued studies as ‘anomalous’ and ‘simple frameworks’ without supporting evidence from other sources. We feel that such claims carry an obligation to point out specific errors of methodology or data, not just recapitulation of personal belief. The burden of proof is still overwhelmingly against the evidence upon which this reports rests. Its foundation is flimsy.”
Enough said about the lack of intellectual rigor, and essentially incorrectness about this piece. More important, I believe, the other assertion in the quote from Cooper’s paper, above, neatly packaged in the sentence “Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care”. What is this “uncomplicated primary care” of which you speak?
The myth is that primary care is about patients with colds and high blood pressure checks. The reality is that it is about people with multiple chronic diseases who need management of those conditions as well as coordination with whatever other specialists they are seeing; preventive services delivered; counseling and “asking for trouble” (“are you safe at home?”); discussion of whatever the other specialist may have recommended; and, of course, caring for acute complaints. This is hard, complex, time consuming and difficult.
(Joshua Freeman, MD is Professor and Chair of the Department of Family Medicine for the University of Kansas School of Medicine. He is author and editor of the Medicine and Social Justice blog.)
http://medicinesocialjustice.blogspot.com/2009/10/uncomplicated-primary-care.html
And…
Health Bills In Congress Won’t Fix Doctor Shortage
By Phil Galewitz
Kaiser Health News
October 12, 2009
Even as Congress moves to expand health insurance coverage to millions of Americans, it’s doing little to ensure there will be enough primary care doctors to meet the expected surge in demand for treatment, experts say.
The American Academy of Family Physicians predicts that the shortage of family doctors will reach 40,000 in the next 10 years, as medical schools send about half the needed number of graduates into primary care medicine.
A proposal backed by Senate Majority Leader Harry Reid, D-Nev., and the teaching hospital lobby to add 15,000 Medicare-funded medical residency positions — a 15 percent increase that would favor more primary care training — was considered dead on arrival because of its $10 billion price tag over a decade.
Instead, the House and Senate overhaul bills would redistribute about 1,000 unfilled residency positions to teaching hospitals that commit to creating more primary care residencies.
Proposals to significantly increase Medicare payments for primary care doctors have gone nowhere in part because the money would come from payments to higher-paid specialists — who, not surprisingly, oppose a pay cut.
Dr. Darrell Kirch, CEO of the Association of American Medical Colleges, said the extra training slots emanating from the redistribution of unfilled residency position would amount to a “drop in the bucket.”
http://www.kaiserhealthnews.org/Stories/2009/October/12/primary-care-doctor-shortage.aspx
Comment:
By Don McCanne, MD
The report by Dr. Cooper and his colleagues, cited by Dr. Freeman, was “A Report to the President and the Congress.” Since it was released only one month ago, this report likely did not influence the current legislation, but it is important because it does represent the cavalier views of all too many within and outside of the health care arena.
One of the promises of reform was to reinforce our primary care infrastructure. Although there are a few measures in the bill such as a nominal primary care bonus and a medical home pilot project, failure to train more primary care physicians will require many patients to rely on expensive care in our emergency rooms and expensive care through often inappropriate, direct self-referral to specialists.
We were promised that everyone would be covered and costs would be controlled. Neither will happen. And now the promise of providing primary care access to everyone will fall far short. Jiggling 1000 existing medical residencies just won’t do it.