National trends in health care and Family Medicine
Jerry Kruse, MD, MSPH
Dean and Provost, SIU School of Medicine
Chief Executive Officer, SIU Medicine
The discipline of Family Medicine and the US health care system stand together at a critical juncture. Health care costs in the US are rising at a rate much greater than the rate of inflation, and all major health outcomes in the US pale in comparison to those of the other industrialized nations. The discipline of Family Medicine has the potential to provide an elegant solution to the problem of healthcare costs and outcomes in the US. But these solutions will not come easily. The discipline itself currently faces a number of woes, including a relative decline in reimbursement for services, increasing regulatory pressures, a nation less interested in preventive medicine and public health, and declining student interest in the primary care disciplines of medicine. What has happened?
From 1980 to 1997, the US experienced a resurgence of interest in primary care, driven mostly by the rise of managed care programs. Immunization rates reached historic highs, the percentage of the population who received appropriate healthcare screening rose dramatically, and healthcare outcomes in the US came closer to the better healthcare outcomes experienced in the rest of the industrialized world. Though flawed in many ways, the managed care programs helped the US place a greater emphasis on preventive medicine, primary care, and public health.
The managed care companies, however, were not accountable to the public, were susceptible to corporate greed, and often placed primary care physicians and their patients in adversarial relationships. In the late 1990’s, the public’s enthusiasm for primary medical care, preventive medicine, and public health waned. Since 1998, the number of US medical students choosing primary care careers has fallen by almost 50%. Since 2000, the proportion of women appropriately screened for cervical and breast cancer has declined. In 2002, the infant mortality rate rose for the first time in 40 years in the US, the only industrialized nation to experience such a rise. The US still trails most of the industrialized nations in life expectancy, death rates from cardiovascular disease and cancer, and infant mortality, and since 2000 the gaps have widened.
Demographic changes will soon occur that will make these problems worse. For the 30 year period from 1970 to 2000, the Center for Medicare and Medicaid Studies (CMS) reported a manageable 13% decline in the ratio full time equivalent workers to Medicare beneficiaries. However, the US is now in the midst of a precipitous linear decline in this ratio. In 2030, there will be 40% fewer workers per Medicare beneficiary than in 2000, and sustaining the healthcare system as we know it will be qualitatively and financially impossible.
The discipline of Family Medicine and our department have great opportunity. There is significant evidence that policies designed to increase the workforce of primary care physicians (PCPs) have the potential to dramatically reduce healthcare costs and to improve quality. This is just what our healthcare system needs. All of this data has been recently reviewed by Starfield and colleagues in the Milbank Quarterly1 and discussed in three commentaries in The Annals of Family Medicine234. This analysis has identified four major areas that have the potential to save our healthcare system:
- The Ratio of Primary Care Physicians to the Total Population. The Dartmouth Center for the Clinical Evaluative Sciences has found that states with 40% more PCPs per capita have significantly better healthcare quality indicators and lower medicare costs. An appropriate increase in the number of PCPs will lead to improved quality and savings of perhaps 60 billion dollars or more per year for the nation’s 41 million medicare beneficiaries. When extrapolated to the entire population, the training of more PCPs could improve health care quality while saving hundreds of billions of dollars.
- The Ratio of Primary Care Physicians to the Total Physician Workforce. Among industrialized nations, those that place a greater emphasis on primary care medicine have better healthcare outcomes and spend a lower percentage of Gross Domestic Product for healthcare. Outcomes are optimized when 40 to 50% of the total physician workforce is made up of PCPs. Currently 31% of U.S. physicians are PCPs. Assuming the current levels of sub-specialization among internists and pediatricians, less than 20% of physicians who began residency in 2005 will practice as PCPs in the future.
- The Personal Medical Home. Practice characteristics associated with improved healthcare outcomes are shown in a table on page 3. These characteristics are the foundation of the Personal Medical Home. Great gains in quality and efficiency will occur if a pervasive network of practices that embody the characteristics of the Personal Medical Home is developed.
- Characteristics of the Healthcare System and Healthcare Policy. Healthcare system characteristics associated with improved outcomes and lower costs include universal or near-universal financial assistance guaranteed by a public accountable body, equitable distribution of healthcare services with respect to regional healthcare needs, low or no co-payment for healthcare services, and comparable professional earnings by primary care physicians relative to other specialties.
Family physicians and family medicine educators must become well versed in this information and must communicate this information to academic, clinical, regulatory, and legislative bodies. Our department clearly understands that policies designed to increase the number of family physicians will result in healthcare of higher quality, personal medical homes for more people, movement toward universal access to care, and lower health care costs. Our department stands ready to train the physicians of the future, who not only will meet the needs of our region, but who also will lead our nation to policies that emphasize primary care, preventive medicine, and public health.”
1 Starfield, Barbara, Shi, Leiyu, and Macinko, James. Contribution of Primary Care to Health Systems and Health. The Millbank Quarterly 2005: 83(3):457-502.
2 Kruse, J. Family Medicine legislative advocacy: Our powerful message. Ann Fam Med 2005:4(3):468.
3 Kruse, J. Saving Medicare: It’s the workforce, stupid. Ann Fam Med 2006:4(3):274.
4 Freeman, J, Kruse, J. Title VII: Our loss, their pain. Ann Fam Med 2006:4(5):465.
5 Kruse, J. Talking the Legislative Talk: the Patient-Centered Medical Home, Ann Fam Med 2007;5:566-7
6 Sepulveda, Martin-J. Bodenheimer, T. Grundy, T. Primary Care: Can It Solve Employers’ Health Care Dilemma?, Health Affairs27, no.1(2008):151-8
Jerry Kruse, MD, MSPH, Dean and Provost, Chief Executive Officer of SIU HealthCare, was a professor and the Chair of the Department of Family & Community Medicine. Dr. Kruse had been the Director of the SIU Center for Family Medicine - Quincy Residency Program for 12 years before being named chair of the department in 1997. He is a student of the interactions of biology and society. He has pioneered cooperative relationships between osteopathic and allopathic institutions and interprofessional systems of care. Dr. Kruse has a special interest in cross-cultural and population health to inform effective policies and improve health care systems. Dr. Kruse serves the SIU School of Medicine as chair of the school’s curriculum committee, the Educational Policy Council, and guided the implementation of a new curriculum in 2000. Dr. Kruse serves the discipline of family medicine as chair of the Legislative Affairs committee of the Association of Departments of Family Medicine. Dr. Kruse is a member of the Illinois State Board of Health, was named Illinois Academy of Family Physicians Teacher of the Year, and is a past winner of the American Academy of Family Physicians Walter Kemp Award, which recognizes excellence in integrative scholarship. Dr. Kruse completed medical school, residency training and a Robert Wood Johnson fellowship in Academic Family Medicine at the University of Missouri at Columbia.