Why are Students Shying Away from Primary Care?

Primary care in the United States is in a state of crisis. Fewer medical school graduates than ever are choosing primary care as their specialty. The American Academy of Family Physicians (AAFP) states that there has been a 51.8 percent decrease in graduates going into primary care since 1997. With the current trajectory, this will leave the country with a shortage of 40,000 primary care physicians by 2020. Couple this with the aging baby boomer population and the system may crumble all together. It is universally accepted that primary care is the backbone of the health care system. It is these providers who serve as the gatekeepers into the system and are ultimately charged with protecting the overall health of individuals and the population.

Drs. Bach and Kocher make the argument that large medical school debt is pushing students into more lucrative fields to pay back their loans as quickly as possible. Their solution is to make medical school free, but then charge people for specialty training. They believe that this would incentivize students away from sub-specialization. As a medical student who will accumulate around $200,000 of debt to be educated (and who is married to a medical student with similar school loans), I clearly understand the financial constraints that this places. However, debt is only a portion of the entire story for why students are not choosing primary care fields. By putting all our focus on the debt issue, it will distract us from finding the real reasons why students are not going into primary care.

Medical students are not exposed to the wonderful sides of primary care medicine. In a general medical practice, the problems are often complex and the solutions are challenging, so it takes months or even years to attack the issues effectively. Students come in and out of primary care services on a month-by-month basis, so seeing any long term solutions to improving and promoting overall health is nearly impossible. Also, primary care physicians across the country are seeking innovative ways to improve patient care. This work is exciting, intellectually demanding, and extremely difficult to implement. We do not get exposed to this aspect of care because often times these projects take years to develop. Another issue is that in the academic setting, primary care is highly disrespected. This should not be that surprising considering academic centers are filled with super sub-specialists who do not fully appreciate how difficult it is to care for the whole patient, rather than a small part. Lastly, primary care, at its core, is about relationships. By being placed temporarily on a service, any relationships formed are superficial and casual.

Focusing solely on debt is a flawed solution. There are many programs for loan-forgiveness if students go into primary care fields. The debt argument looks dramatic on paper, but the real issues for why students are not going into the field are much deeper. Those are the areas on which we need to focus our attention; provide students with the chance for continuity of care, involve them in clinical innovations, and show them firsthand that the field is respectable and worth pursuing.

BWC

Response to Op-Ed: http://www.nytimes.com/2011/05/29/opinion/29bach.html?_r=2

Renegotiating Reimbursement: Good Policy or Good PR?

Yesterday Partners Health Care, Massachusetts largest health system, voluntarily disposed of its current contract with Tufts Health Plan and renegotiated a new four year agreement that is expected to lower the health reimbursements they receive by about $105 million dollars over the next four years.

This is significant.  In a conversation I had with a Partners executive two months ago he shared that the Partners negotiating team often leaves their contract meetings with groups like Tufts feeling "proud" of the deals they are able to strike with health insurers.  My impression was that Partners, with the largest market share of any hospital system in Massachusetts, knows it can throw its weight around and does quite willingly.

Not any more.  Partners' decision to rework its contract with Tufts, following a similar renegotiation last year with Blue Cross Blue Shield that is estimated to save $240 million dollars, was likely due to the following.

• Altruism: although not likely the biggest factor, Partners CEO Gary Gotlieb did state that one reason for accepting smaller increases in reimbursements going forward is the growing burden of health care costs on families and businesses.
• Government pressure: the political environment in Massachusetts, and in many areas of the country, is such that all hospitals understand that costs must be cut voluntarily or else the government is likely to do it for them.  With Massachusetts congress toying with rate setting as a way to control out of control medical costs, hospitals would rather be a part of a pre-emptive solution.
• ACOs: Partners was recently announced as one of 32 Pioneer ACOs set to begin this year.  As part of the agreement, ACOs commit to generating at least 50% of their revenue from business models similar to that of the Pioneer Medicare program.  This can only be accomplished through agreements with insurers, employer health plans, and/or Medicaid (called "Participation of Other Payers" in the CMS Pioneer ACO Fact Sheet).  As part of Partners' new agreement with Tufts, approximately 70% of the patients in the plan will now be reimbursed via a global payment structure, shifting significant risk to Partners and forcing them to find ways to contain costs for all their patients, not only the Medicare population.  This is exactly the goal of the ACO, and to the extent that Partners' participation in the Pioneer program is influencing this new agreement with Tufts, the ACO model is succeeding.

Whatever the reasons, I applaud any move by hospital systems to voluntarily forego future payment.  Additionally, I applaud any move toward global payments and the taking on of risk by hospital and physician groups.  However, scale must always be kept in perspective.  While $105 million dollars is no small amount, with an annual budget of over $8 billion dollars and capital expenses totaling $3.2 billion dollars over 5 years, it doesn't seem like so much.  Additionally, there has been little talk of where the $105 million dollars in "cuts" to Partners bottom line will come from.  The hope is that money will be saved through care coordination and a focus on the high utilizers or perhaps a reduction in capital investments year over year.  I imagine that if savings do not materialize, however, chronically underfunded mental health and substance abuse programs will instead be on the chopping block, and this would be an unwelcome result.

Despite my significant skepticism of the hospital market environment in Massachusetts and at the risk of being duped by what may turn out to be simply a PR move, I am encouraged that, whether it be altruism, the political environment, government policies, the market at work, or some combination of these, the system appears to be working.  At least for today.

An ounce of prevention is worth a pound of cure....or is it?

Is it possible that Benjamin Franklin could be wrong? I tend to trust in the wisdom of this renowned polymath. He was a statesman, scientists, printer, inventor, author, philosopher, and diplomat. The only person I have ever known who is more knowledgeable in a wider variety of topics than him is the great Jason Kroening-Roche. However, could Franklin be mistaken such that prevention is not cheaper than the costs of cure? Intuitively speaking, preventing something today is less costly and should save a lot of time, energy, and money compared to dealing with the aftermath of full on disease manifestations. Joshua Cohen, however, makes a convincing counter argument against the cost saving effects of prevention, at least on the population level. Maybe an ounce of prevention is actually worth just an ounce of cure.

As an aspiring primary care physician, I often find myself making arguments in support of primary care on the grounds that prevention is cheaper, both financially and generally. Cohen does not reject prevention altogether, but he argues that our preventative efforts are neither as cost-saving nor cost-effective as we are inclined to believe. Smoking cessation, colorectal cancer screening, and flu immunizations are good preventative measures that protect a lot of people at a relatively low cost, but many diseases, which are not as common in the population, do not yield significant benefits from a cost standpoint.

Cohen and his team did a systematic literature review to look at the overall cost-effectiveness ratio (in terms of $ per QALY) of prevention versus treatment for existing conditions. The lower the ratio, the better as that indicates less cost for one quality adjusted life year (QALY) gained. His results are surprising. He found that the cost-effectiveness ratios for prevention and treatment were relatively the same (see graph above). He makes the argument that cost of treatment of disease is nearly as prudent as investing financially in prevention. He does state that preventative interventions, particularly those aimed at high risk populations, do in fact save money, but broadly generalizing that prevention is cost-effective or cost saving is not always the case.

I am intrigued by this article and found it surprising, but I have a couple criticisms. First, what is cost-effective and what is not is a value judgment. He may not think that spending $29,000 for one QALY on combination anti-retroviral therapy is a sensible investment, but I do. Next, he includes secondary prevention efforts as treatment. It seems that a lot of secondary prevention efforts would in fact prevent many diseases from coming to full fruition. He uses the example of an intracardiac defibrillator which cost $52,000 per QALY. However, there are many secondary prevention efforts, like statins for patients after they have a heart attack to prevent a recurring event, which yield good results at a low cost. I would be interested in seeing his analysis if he included secondary prevention and primary prevention together and compared it to tertiary measures. Lastly, Cohen does not tell us how he discounts the future costs of treatment or the future benefits of prevention. This could have a large effect on the cost effectiveness ratio depending on what discount rate he used.

I am not quite ready to discount Franklin’s wisdom on prevention as of yet, but Cohen has at least made me stop and reconsider my argument.

Reference:

Cohen, J., Does Preventative Care Save Money? Health Economics and the Presidential Candidate, New England Journal of Medicine, 2008; 661-663

BWC

An Evening with Dr. Blumenthal

I just got home from a fascinating 3 hour talk with Dr. David Blumenthal. You can read more about him here, but he is basically one of the leaders in the quality field of health care and recently spent 2 years working in the Obama administration as the head of Health Information Technology (HIT). He came to speak to our US health policy class at the Harvard Kennedy School of Government and a smaller group of us had dinner with him afterwards. I wanted to share a couple things he spoke about that I found compelling.

Cost
Dr. Blumenthal answered one question about cost containment, which has been a hot topic in the national debate of late and something I've been reading quite a lot about. His answer was not novel nor complicated but brought my attention back to the reality of our health care system. 5% of the patients account for 50% of the costs. Atul Gawande wrote about this in his The Hotspotters article in January and countless others have shed light on this as well. Blumenthal's answer was simple: "Go where the money is." He spoke about better coordinating care, keeping these patients with multiple chronic diseases out of the ER and hospital, and actively pursuing them to better manage their care. Call them at home everyday, visit them in person, lay out their 15 or 20 medications for them, and fill in every gap where their care is dropped.

My reflection is this: If we are serious about reducing health care costs, and there is no doubt that we now are, we must work tirelessly to first find these patients in our health care system, even if they are not our own. We must proactively engage them in the medical system so that we are not caught reactively responding in extremely inefficient ways. We must think system-wide about the ways in which we currently fail to fill the gaps and bring all of the sometimes dozen providers for these patients into the discussion. And we must find innovative ways to engage the patients and their communities to embrace healthier attitudes and behaviors the are community driven.

Health Information Technology
We couldn't spend three hours with Dr. Blumenthal without talking about health IT, something he spent the last two years of his life on in Washington. Here are some of his reflections:

-Health IT is rapidly expanding across the country and has doubled in the last 2 years
-Competition and decentralization of HIT is good because it is driving innovation in the field. There are now over 1300 different private companies providing HIT and the innovation they are creating will have enormous positive impacts decades into the future. Quelling that force now in favor of a more unified system is the wrong thing to do.
-That being said, cross-talk is an important part of the future of our electronic medical records (EMR). Patients need to be able to take their records with them when changing locations and health systems. The government has put in place standards that are being adopted by the private HIT enterprise. Providers will also have to achieve some standard of meaningful use in the coming years to earn the substantial savings available through the stimulus bill that passed in early 2009. It is up to providers to put pressure on the health IT companies they work with to comply with these standards
-Privacy isn't nearly as big an issue as people say it is. Technology has been developed. Barriers to the sharing of information is primarily systems and politically generated.
-He doesn't have much sympathy for small practice physicians who are complaining about the cost of switching to EMR. The previously mentioned stimulus bill has provisions that will more than pay for their implementation, provisions that amount to $100 of tax revenue per American citizen to make this happen. He says this indicates that the public prioritizes it and it is high time providers do too.
-He is very optimistic that HIT will continue to grow, and it is necessary, but not sufficient, to attending to many of the problems in our health care system.

Quality
Dr. Blumenthal is a national leader in the quality movement in health care. He spoke at length about this during our structured lecture with him. Quality essentially was put on the map in the late 1990's after the Institute of Medicine's report in 1999 called "To Err is Human." This was followed in 2001 by another report from the IOM that Blumenthal described as a seminal document called "Crossing the Quality Chasm." Prior to these reports, quality was not on the policy map as much of an issue.

Quality is something that I admit I don't think about much. I tend to be of the mindset that our health care system is pretty darn good, but I often compare it to other places I've been in the world that have far worse health systems but also shoddy electricity. This fails to ask the important question, "How can we do better?" If I truly reflect on my medical training, I'm appalled at much of what goes on in the hospital and even in the outpatient setting. Care is so fragmented that providers are often very under-informed about the stage of care delivery a given patient is in or a recent change in treatment plan proposed by a different physician or service. The bottom line is that lots of bad things happen all the time with even more near-misses to make even the most inexperienced clinician worried.

This is what Dr. Blumenthal has been trying to remedy. So while I often push quality issues to the back of my mind, they are an area we can drastically improve on. We will save money if we keep people's blood pressures and hemoglobin a1c's under better control and don't order unnecessary costly imaging studies. We will save lives if we prevent infections in the hospital by washing our hands. And we will make much better clinical decisions if we have electronic records that remind us when we are doing something outside best practices. I think we can do a lot better to improve quality and I am excited that through better care coordination and the smart use of HIT we can work to accomplish so much more than simply containing costs. After all, our primary goal is helping patients get and stay healthy.

JK-R

Price Discrimination and Hidden Negotiations

Uwe Reinhardt of the New York Times blog Economix recently wrote about an issue that has been perplexing me of late. How do hospitals and providers in the same state and even the same community charge such different prices for the exact same services they provide? Similarly but in the reverse, how do health insurance companies, seemingly competing with each other in the same market, pay such different prices for the exact same services? Isn't our free market health care system supposed to lower costs through good old-fashioned market competition?

I thought so, but it doesn't seem to.

The contribution of high and rising unit costs to our overall health cost crisis was the subject of the recent September Health Affairs issue. The same cost conundrum was detailed in 2003 and has been described in many other times and places as well. In addition to describing the problem, the recent Health Affairs issue also includes a section devoted to "strategies to cut costs" which includes the following ideas: a weight loss program, telehealth innovation, successful collaborative care models, and bundled payment reform. But haven't we seen this all before?

None of these ideas address the fact that price discrimination and hidden negotiations are contributing to the rising costs in our system. There seems to me to be three (overly simplistic) options to reduce high unit costs.

1. Improve price competition among payers and providers. Massachusetts recently introduced recommendations on provider price reform. One recommendation was to open up the secret negotiations that now take place between hospitals and insurance companies in an effort to introduce transparency to the process. The goal is to reduce some of the variability that now exists by introducing real competition back into the "market."
2. The second idea was also approached in the same recommendation set and is considerably farther left. Regulate prices. If the market can't be relied upon to drive competition, the other option is to strip competition from the system entirely. In this setting I can imagine some immediate concerns: heavy government control, decreased innovation, lower salaries, not mention a serious lack of political feasibility. There is a third option, however.
3. Many countries (Germany, Switzerland, Belgium) operate systems whereby providers and payers negotiate prices on a regional level, but in a coordinated fashion. The negotiations do not occur between individual hospitals and insurance companies, but rather take place between formed coalitions. This encourages active participation, allows for regional variability, but eliminates the price discrimination and hidden negotiation practices currently employed in the US.

Even with a very introductory understanding of economics I am able to see that the current system of price setting is extremely inefficient. It neither allows the free market to function (which requires widely available information among all parties involved) nor for government oversight. In the current system monopoly (in markets where large providers dominate) and monopsony (in markets where large insurance dominates) run free. Both are market failures.

We must move from a hidden process of back-room deals to a more transparent and competitive system. If we are not able to, government price regulation may be our only choice, because our high and growing unit costs are entirely unsustainable.

JK-R

Can the United States Learn from Brazil's Primary Care Model?

Brazil has seen huge changes in the past several decades in their political and social structure. Prior to democratization in the 1980’s, the country had been under several decades of military rule. After the authoritarian rule, socio-political reformation began to take shape which included an overhaul of their health care system. The belief that health is a universal human right became more widespread throughout the Brazilian culture and with this in mind, the National Health System (SUS) was created in 1988 and implemented in 1990. Since implementation of SUS, Brazil has seen huge improvements in health outcomes including increased life expectancy, decreased infant mortality, and decreased deaths from infectious diseases.

A cornerstone of the SUS is the Family Health Program (PSF) which functions as their primary care delivery system. The PSF was established in 1994 as a way to meet universal access goals, better coordinate care, and focus on prevention. The PSF’s focus is on family and community health which encompasses prevention and public health goals. Under PSF, family health teams, which consists of one doctor, a nurse, an auxiliary nurse, and 4-6 community health workers cover a geographic area which includes no more than 5,000 patients. Community health workers are vital to the team as each community health worker is responsible for about 120 families and they make home visits to each of these families once per month. The community health workers’ primary focus is on child and maternal health, but they have been instrumental in health promotion, education, medical adherence, public health actions (i.e. sanitation), chronic disease management, and triage support.

The PSF is highly decentralized with most authority placed on the municipalities. The PSF program has been successful in getting to the majority of the population as family health teams are found in 85 percent of municipalities serving over 98 million people. Despite the large coverage, the PSF program only takes up 8 percent of the federal health care budget.

The PSF program has been shown to be very effective in improving health outcomes for Brazil. Access to care has increased by over 25 percent since its origination in 1994. Life expectancy has increased from 67 to 72 years, immunization rates for Tetanus, Diphtheria, and Pertussis is over 95 percent for all children 1 year of age, and infant mortality has decreased from 48 per 1000 to 17 per 1000. A reputable study by Guanais and Macinko focused on postneonatal mortality as a proxy to assess success of primary care delivery. It is argued that the postneonatal period, ranging from 30 days to one year, reflects success in primary care goals of nutrition, immunization, sanitation, breast feeding, and prevention of respiratory and diarrheal infections. They found that between 1998 and 2006, the postneonatal death rate decreased from 14.24 to 6.92 per 1000 children while at the same time PSF coverage increased from 8.74 percent of municipalities to 60.90 percent. Their published paper accounted for increases in clean water, decreased illiteracy rates, and other confounders and through regression analyses determined that the family health teams decreased postneonatal death rates by 0.86 per 1000 compared to communities without teams.

The PSF does not come without some problems, however, and need to be mentioned. The decentralized nature of the program makes it difficult to ensure quality between geographic regions. The federal government collects money, but the money is allocated to municipal governments who are ultimately in charge of managing their budget and health care delivery. Problems seem to arise most in the northeast region which is more socioeconomically depressed than the central or southern regions. As a result, the northeast has a higher infant mortality rate, more deaths from infectious diseases, and lower life expectancy. Not surprisingly, many municipalities in the northeast do not have family health programs, partly because it is difficult to recruit and retain health providers for this region. Additionally, corruption is a problem with some municipalities which results in allocated money not being used for health care expenditures. These problems create conspicuous disparities in access and health care outcomes between different municipalities.

Another problem faced is the difficulty of integrating the family health teams with local hospitals and specialist care. Some municipalities have more success than others in working with the private sector. Naturally, the more coordinated and integrated the care is, this results in better available health care for Brazilians. Lastly, the emphasis on improving primary care has come at the sacrifice of providing good hospital and tertiary care. Brazil’s public hospital system only provides 35 percent of hospital beds in the country with the remainder made up of by private hospitals. The public hospital system is overcrowded and has large variability in quality.

As the United States works to come up with solutions for improved primary care delivery and access, it may be prudent to look outside of Europe and Canada for ideas. Arguably, Brazil’s primary care model has seen some of the greatest health improvement of any country in the world through their innovative decentralized method. I feel that U.S. could benefit from a team based approach. Teams are seen to an extent in our patient centered medical homes, but the addition of community health workers could facilitate improved chronic disease management, health promotion, behavior change and support, and medical adherence. Most importantly, Brazil has shown us that by investing in primary care, the health of the population can be greatly improved. As we continue to work towards improved health systems and primary care delivery, let’s not forget to keep Brazil in mind.

BWC

Resources:

Frederico C. Guanais and James Macinko, The Health Effects of Decentralizing Primary Care in Brazil, Health Affairs, 28, no 4 (2009): 1127:1135

Michael Kemp, Cracks Appear in Brazil’s Primary Health Programme, The Lancet, vol 372 (2008): 877

Mathew Harris and Andrew Haines, Brazil’s Family Health Program, BMJ 2010; 341: c4945

Paim, J., Travassos C., Almeida, et al., The Brazilian Health System: history, advances, and challenges, The Lancet, 2011; 377: 1788-97

Innovation in Physician Training

Patient-Centered Medical Homes (PCMH’s) are presented as a care delivery innovation that has had success in the realm of increasing quality of care while decreasing costs. At its core, the PCMH seeks to strengthen primary care, leading to coordinated care, improved access, and ultimately reduced costs. However, the dark irony of the success of the PCMH model is that as primary care demonstrates its ability to serve as a hub for care coordination while reducing cost, primary care physicians (PCP’s) are dwindling in proportion of the physician work force. Perversely designed fee schedules have created a dramatic income inequality among physician specialties, strongly steering medical students away from generalist careers. While many factors ultimately influence student specialty choice, medical students are hard pressed to choose generalist careers while income disparity remains so troublingly wide.

Further, essential to the success of PCMH’s are functional teams. Looking at the results of the 2006 Group Health Cooperative model, strong PCP leadership was identified as a critical factor for the success of organization transformation into a PCMH[1]. However, current undergraduate and graduate medical training does not search out these skills in its applicants, nor does it provide comprehensive education for how to develop these practice tools. Strong leadership capable of excelling at the challenges of practice management are necessary for PCMH’s to become a widespread national success story, yet medical education has not responded to the growing need for these additional physician skill sets. Biomedical science training and clinical knowledge, the current mainstay of medical education, is not enough to produce physicians competent for current health challenges. Physicians, especially PCP’s, must be taught how to work and lead within teams, manage practices, motivate members of the care team, integrate health IT, and adapt quickly to practice innovations. These competencies are critical for the success of PCMH’s and ultimately care delivery transformation.

The reported success of PCMH’s is exciting; though many details need to be ironed out to rigorously define the characteristics of successful models, the early victories among differing patient populations provide evidence that the key organizing principles of the PCMH are widely applicable across our nation. However, to achieve this dream of coordinated, high value care, it is necessary to rethink medical student training and physician payment. Large income disparities are not sustainable if we are to attract the number and quality of primary care doctors necessary to lead transformation in care delivery. Further, medical education itself must innovate in order to equip its graduates to practice within these new models.

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[1] Robert J. Reid, Katie Coleman, Eric A. Johnson, Paul A. Fishman, Clarissa Hsu, Michael P. Soman, Claire E. Trescott, Michael Erikson and Eric B. Larson The Group Health Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers Health Affairs, 29, no.5 (2010):835-843