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State of the Nationís Health Care 2009

Primary Care: The Best Medicine for Better Health & Lower Costs

Oral Remarks
Jeffrey P. Harris, MD, FACP
The American College of Physicians

Thank you for joining us today for this report from Americaís internists on the State of the Nationís Health Care.

Until recently, I practiced in a rural community in Virginia with a population of 40,000 people. The office in which I practiced focused on the delivery of primary care and nephrology. I was a Clinical Associate Professor of Medicine at the University of Virginia (UVA).

I have practiced internal medicine for nearly 30 years. My partners and I had the pleasure of having 3rd year UVA medical students join us for the community based teaching of internal medicine. This year I had the good fortune to be President of the American College of Physicians representing 126,000 internal medicine physicians and medical students. The ACP is the largest physician specialty organization in the United States. It is the second largest physician membership organization in the country.

In 2009, the State of Americaís health care is poor.
We have too many uninsured.
We have too few primary care physicians.
We spend more for health care and get less in return than most other industrialized countries.

At this same event in 2006, the American College of Physicians warned that primary care was nearing collapse in the United States. Regrettably, primary care is in even more critical condition today than it was just three years ago.

A few weeks ago, the Institute of Medicine reported that 16,000 additional primary care physicians are needed now to meet the demand in currently underserved areas. Two recent studies project that the shortages of primary care physicians will continue to grow to more than 40,000.

The primary care shortage is occurring at a time when the need for primary care is greater than ever. An aging population, with growing incidences of chronic illness, will increase the demand for general internists and other primary care doctors. If President Obama and the new Congress are successful in ensuring that all Americans have access to affordable health coverage, there must be an increased focus on expanding the ranks of primary care physicians to meet that demand.

Our analysis of the health care delivery system in the US and 12 other industrialized nations indicates that this nation would be well served to expand primary care from the current 30 percent of our physician workforce. We found, for example, that nations where primary care physicians are 50 percent of the total physician workforce have better outcomes and lower health care costs. We are calling for the federal government to convene an expert advisory group to recommend specific targets and the numbers and proportion of primary care physicians appropriate for the United States

The primary care shortage is occurring even though decades of research tell us that primary care is the best medicine for better health care and lower costs. More than 100 studies, referenced in the findings section of this report, support the findings of the 12 nation analysis and demonstrate that primary care consistently is associated with better outcomes and lower costs of care.

Today, we are calling on President Obama and the new Congress to take immediate, sustained and dramatic steps to accomplish two essential and interrelated goals:

  • Provide affordable and accessible health care to all Americans.

  • Provide every American with access to a primary care physician.

Programs to expand health insurance coverage must go hand-in-hand and be implemented simultaneously with reforms to expand the primary care physician workforce.

Given the fact that it takes a minimum of seven years to train a primary care physician (medical school and residency combined), the U.S. cannot afford to delay implementation of policies to attract more new physicians to primary care and to sustain those already in practice.

Therefore, policies to expand primary care workforce capacity need to be implemented immediately to influence the career choices of medical students and physicians already in residency programs, and the retirement and career decisions of primary care physicians already in practice.

Expansion of coverage for any subset of the uninsured population must be accompanied by a simultaneous, sufficient, and sustained set of policies to assure that there will be enough primary care physicians available to take care of them. Nearly one half of the ACPís members are internal medicine subspecialists. Many of those subspecialties, like other fields in medicine, have a need to expand their numbers because our population is increasing and it is aging. However, the degree to which the ranks of general internists and other primary care physicians must be expanded is substantially greater.

The recent experience in Massachusetts is telling. After expanding affordable coverage to about 400,000 more of its citizens, the newly insured of Massachusetts often could not find physicians. There were simply not enough primary care physicians to care for all those patients. Having affordable coverage is of little value when there is no one who can provide you with care.

This report we are presenting today proposes specific policies that the federal government must take to achieve a simultaneous expansion of coverage and expansion of primary care workforce capacity. ACPís recommendations include:

  • Programs to help people keep health insurance coverage during the economic downturn followed by a comprehensive plan to achieve affordable coverage for all.

  • Medicare payment reforms to make primary care competitive with other specialty choices.

Medical students and young physicians should make career decisions based on their interests and skills, instead of being influenced to a great extent by differences in earnings expectations associated with each specialty. Yet there is extensive evidence that choice of specialty is greatly influenced by the under-valuation of primary care by Medicare and other payers compared to other specialties.

Currently, the average of earnings of physicians that provide primary care Ė family physicians, general internists, and pediatricians Ė is approximately 55 percent of the average of the earnings for all other non-primary care physician specialties.

Every specialty of medicine provides young physicians the pleasure of patient contact and intellectual stimulation. When they complete school with an average debt of $139,000, should we be surprised that the disparity of earnings among specialties affects their career choice? When they have so much debt before opening an office, purchasing a home, or having a child, should we be surprised that few are choosing primary care as a career?

The data are compelling that expanding the base of primary care in the United States holds the most promise for improving the quality and lowering the cost of the health care. The federal government must establish a target goal for raising primary care reimbursement to make it competitive with other specialty and practice options

For instance, Medicare and all other payers would need to increase their payments to primary care physicians by 7.5-8 percent per year over a five year period, above the baseline for all other specialties, to bring the average of the median earnings for primary care physicians to 80 percent of those for all other specialties.

Additionally, such targets could also be adjusted to take into account expansion of existing programs and development of new ones to eliminate student debt for physicians selecting primary care careers, so that the combined differential between debt and expected earnings is comparable to other specialty choices.

Other countries have done this. Englandís National Health Service increased the pay for primary care doctors by almost 60 percent over the past several years.

Our recommendations also include:

  • Transition to a new payment and delivery system for primary care modeled on the Patient-Centered Medical Home.

  • Reduction in administrative requirements imposed on primary care physicians and their patients; and

  • A call for President Obama to issue an Executive Order on Primary Care so that all federal agencies are working together in a seamless and coordinated manner to expand the primary care workforce.

We propose additional reforms to improve the quality and efficiency of health care for all patients, not just those seen by primary care physicians.

The data presented in the two papers we have published on these issues are disturbing. The need for a dramatic expansion of the primary care workforce is compelling and it is nationwide.

My community offers an example. The search for a new internist to join any practice is a multi-year search. One group offers a representative sample. Winchester Internal Medicine Associates, founded more than 60 years ago, is a widely respected group of physicians. They have spent the last 3 years trying to recruit another young internist to join them. As most of the internists in the group were trained at the University of Virginia, they turned to UVA first in their search. Over each of the last 3 years, the University of Virginia has had 30 internal medicine residents per year. Over each of those years, only one out of the 30 residents planned to enter primary care internal medicine. That group of physicians is not only a sterling practice for a young person to join, the hospital to which they admit is a wonderful place to practice medicine. The medical center has been recognized by Solucient as being in the top 100 hospitals in the nation twice in the last four years. Additionally, the community is a very appealing place to raise a family and conduct your life. Yet, it took this group 3 years to add an internist.

During my travels around the United States this year the shortage of general internists is a recurring theme in every state I have visited. Behind the data are thousands of communities and millions of patients not getting the care they need.

The experience of other nations has taught us that providing affordable health care for all Americans and providing an adequate primary care workforce to deliver it holds promise for improving the quality and lowering the cost of health care in United States.

Every day, in hospitals and in emergency departments, we admit patients with advanced illnesses and preventable problems who have no health insurance. So often good primary care could have prevented the problem, saved the person from the burdens of illness, and saved the cost of an expensive hospitalization

The problems are large, and so must the solutions be large. Small measures will not reverse the collapse of primary care. Small measures will not provide all Americans with health insurance coverage.

A better health care system must result in everyone having health insurance coverage, and everyone having access to primary care.

Now, I am pleased to introduce Bob Doherty, the senior vice president of ACPís division of government affairs and public policy. He will describe ACPís legislative, regulatory and general advocacy recommendations that will, indeed, result in Primary Care being the Best Medicine For Better Health Care & Lower Costs.

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