The discipline of family medicine stands at a critical juncture. We face the pressures of dwindling medical student interest and a shift in workforce policy toward a greater emphasis on market-driven forces. Population-based studies show that care provided by family physicians results in lower health care costs and improvements in quality and health outcomes. The regulatory influence of government agencies upon health policy has never been more important than it is now.
The Academic Family Medicine Advocacy Alliance (AFMAA) organizes legislative activities for ADFM, STFM, AFMRD and NAPCRG. At the annual Congressional Conference in April 2005, our members met with legislators and government officials. Senator Barak Obama expressed a clear understanding of our character when he pronounced: “Family physicians are the doctors who always put the interest of their patients ahead of their own.” This sentiment was shared by other legislators who, if properly informed, could be champions for policies that will benefit the health of the people of the United States. Unfortunately, they are not yet properly informed.
THE POWER OF THE PROPER COMPOSITION OF THE PHYSICIAN WORKFORCE
Legislators were attentive to information from recent studies of health outcomes, which indicate that higher quality care can be achieved at a lower cost when the physician workforce is composed of the appropriate proportion of generalist physicians.1–6 These data suggest a potential cure for a health care system that Senator Obama described as “in the throes of a meltdown.” They were captivated by this information because the changes necessary for improvement in quality and reduction in spending could be described in simple terms. Even though this information is the compelling foundational argument for all legislation that supports the practice of family medicine, it is neither understood nor well articulated by most family physician clinicians or educators.
The studies from Johns Hopkins1–3 and Dartmouth4–6 are powerful population-based investigations that examined health outcomes and quality indicators in industrialized nations, states, and counties. In composite, the data suggest that optimal health outcomes occur when 40% to 50% of the physician workforce is made up of family physicians, general internists, and general pediatricians.
The Dartmouth studies examined entire Medicare data sets for several years, and compared the spending by each state with 24 quality indicators.4–7. As annual spending per Medicare beneficiary increased, quality of care declined significantly. As the number of generalist physicians increased, the quality of care improved and the costs declined. Conversely, as the number of specialist physicians in the population increased, the quality indicators declined and the costs rose.
States at the 75th percentile of quality spent about $1,600 less per beneficiary per year than states at the 25th percentile, and states at the 75th percentile in spending had about 40% fewer generalist physicians per capita than states at the 25th percentile (2.4 vs 3.9 per 10,000 people). An appropriate increase in the proportion of generalist physicians will lead to improved quality and savings of perhaps $60 billion or more per year for care of the nation’s 41,000,000 Medicare beneficiaries.
Radical changes in the US health care system must occur to support this balanced workforce, including examination of medical school admissions, increased reimbursement for generalist physicians who provide personal medical homes for patients, and incentives for systems that demonstrate high quality. The balance of spending for health care must shift toward preventive medicine and public health policies that provide access to health care for all.
Two things must be done to properly inform those who make laws and implement policy. First, we must develop enduring relationships with our legislators. We must also become conversant in the studies that show the positive effect of our discipline on the nation’s health outcomes. Our legislators already know that we are passionate about the health of our patients and our nation. Now we must become their trusted advisors who can demonstrate that our passion improves outcomes and lowers costs. They will be eager to listen to this story.
- © 2005 Annals of Family Medicine, Inc.
