As the last three posts have shown, the primary care infrastructure of the U.S. health care system is crumbling, overrun by specialization, sub-specialization and market forces. As a result, access to primary care is not available to a growing part of our population, costs go up as value, quality and outcomes of care go down, and any accountability within the market-based system remains out of reach. The “reform” legislation of 2009 cannot be expected to alleviate these fundamental problems, “building” as they do on our present flawed system of financing and delivering health care. Since all incremental efforts to reverse these trends have failed, we need more fundamental approaches.
Space here does not permit fleshing out the necessary steps to real system reform that would also facilitate the rebuilding of primary care. Briefly, however, most if not all of these approaches will inevitably be required. In their approximate order of priority, they are:
1. Adopt universal health care coverage through single-payer national health
insurance (NHI). This is the only way we will ever get universal coverage so essential for optimal care of individuals as well as our population. It will help to enable the other elements of needed reforms by forcing new approaches to financing care. Exploitive profiteering can be eliminated while simplification of administration can bring greater efficiencies.
2.Rethink the goals of medicine and the paradigm of health care. We have developed a health care system that overemphasizes the reductionist biomedical model, gives short shrift to behavioral and social aspects of illness, and all too often, continues high technology interventions to the point of futility. These are some of the steps that could help to improve the health of individuals as well as our population: closer collaboration between medicine and public health; increased emphasis on health promotion and disease prevention; improvement of chronic illness care; increased emphasis on mental health services; and earlier shift to palliative care when cure is not possible.
3. Change how physicians are paid. Payment systems for physicians are complicated and are subject to being gamed for maximal profit by many physicians and their employers. Managed care of the 1990s placed many restrictions on care in an effort to increase the profits of HMO plans. Overvalued reimbursement of many specialized and procedural services is a major factor in the decline of primary care. By contrast, its services are time-consuming, require broad clinical competence, are more cognitive and less procedural, and are under-reimbursed. While there is room for various reimbursement methods, essential primary care services are best offered without cost-sharing with patients, and the wide gap between compensation of specialists and generalists must be narrowed.
4. Shift to evidence-based coverage decisions. We can no longer afford to offer services that don’t work, are not cost-effective, or are even harmful. But our present methods of deciding on coverage and reimbursement are heavily influenced by politics, lobbying, and the interests of industry and vested medical organizations. Many new technologies are brought to market without objective assessment of their benefits and value by disinterested experts. Other industrialized countries around the world have developed effective ways to apply the best available clinical evidence to this decision-making process, but market forces have resisted such approaches in this country.
5. Re-design primary care based on generalism and interdisciplinary team practice. Past ways of organizing primary care practice no longer work for a variety of reasons. Given the pressures of time and the complexities of practice today, many primary care physicians are burning out and not being replaced. The delivery of primary care services needs to be re-engineered, with primary care physicians seeing a smaller number of patients with more complex problems, working with other team members in their areas of expertise, and coordinating care being provided by consulting specialists.
6. Re-establish a generalist orientation in medical education. Despite the development of new education programs in medical schools and hospitals over the last three decades, the aura of specialization has dominated medical education. Medical school graduates have opted in droves for the increased compensation and more attractive life styles of non-primary care specialties. A physician workforce goal needs to be established for a 50:50 balance of generalists and specialists, together with financing changes that favor institutional change, changes in medical school admissions policies, and expanded scholarship and loan repayment programs for students and residents bound for primary care careers.
7. Create a new ethical environment of accountability in medical practice, education and research. We have a medical-industrial complex, wherein the higher the volume of services that is delivered to patients, the higher the revenues to the providers and suppliers. About one-third of health care services are either inappropriate or unnecessary, some even harmful. (Wennberg, JB, Fisher, ES, Skinner, JS. Geography and the debate over health care reform. Health Affairs Web Exclusive W- 103, February 13, 2002) This problem is driven by widespread conflicts-of-interest among physicians, industry, and others, as described in my 2008 book Corrosion of Medicine: Can the Profession Reclaim Its Moral Legacy? All past efforts to rein in these conflicts-of-interest have been ineffective, and the patient is at a disadvantage in evaluating what services are, or are not, worthwhile.
8. Expand primary care and systems-oriented research. The annual budget for the National Institutes of Health (NIH), with its focus on biomedical and disease-oriented research, is about 75 times that of the Agency for Healthcare Research and Quality (AHRQ), the principal source of federal funding for primary care and systems-oriented research. Given the urgency of building a better delivery system based on primary care, we need a far greater investment toward that goal.
9. Tighten regulatory processes and policies. Our regulatory apparatus is too industry-friendly, is understaffed, and needs more federal funding and independence from industry. Right now, the fox is in the hen house. One of many examples: an artificial hip manufactured by a subsidiary of Johnson & Johnson was designed to last about 15 years, but has been failing worldwide at unusually high rates after just a few years. It had been approved through a loophole with lax testing requirements. The company continued marketing its defective product even after whistle-blowing efforts by orthopedic surgeons, and the U.S. still has no tracking system to monitor the experience of artificial hips. (Meier, B. The implants loophole. New York Times, December 17, 2010: B1))
10. Increase protections for patients and physicians against medical malpractice liability. Patients need protection from medical injuries due to negligence while physicians need protection from frivolous lawsuits. But this issue is typically exaggerated (especially by conservatives) as a major cause of health care inflation. That is not the case. Though “defensive medicine” is common, the annual costs of the medical liability system make up only 2.4 percent of total health spending. (Mello, MM, Chandra, A, Gawande, A, Studdert, CM. National costs of the medical liability system. Health Affairs 29 (9): 1569-77, 2010) While this whole issue is immensely complicated, useful steps that will help to protect patients from injury and physicians from unwarranted liability for malpractice include: increased emphasis on patient safety in medical education and clinical practice; increased use of evidence-based practice guidelines as “safe harbors” for physicians; and increased use of arbitration.
Although the current political landscape is unfavorable for this kind of forward thinking, time will probably tell that what seems utopian now is absolutely required not too far down the road.
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Adapted in part from my latest book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Healthcare, 2011)
John Geyman, M.D.
Professor Emeritus of Family Medicine, University of Washington
Past President of Physicians for a National Health Program