A dysfunctional health care system and an aging population spell trouble for Medicare. For the 30-year period from 1970 to 2000, CMS reports a manageable 13% decline in the ratio of full-time equivalent workers to Medicare beneficiaries. However, the United States 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 Medicare as we know it will be impossible.
Starfield and colleagues have recently published a comprehensive review of the effect of primary care on the quality and costs of health care systems.1 This review demonstrates that policies designed to increase the workforce of generalist physicians have potential to dramatically reduce costs and improve quality. This is just what Medicare needs.
As we discuss strategies for Medicare reform with our legislators and regulators, 4 major areas identified in the Starfield article must be well articulated.
THE RATIO OF PRIMARY CARE PHYSICIANS TO THE TOTAL POPULATION
We previously summarized the work of the Dartmouth Center for the Evaluative Clinical Sciences.2 States with 40% more generalist physicians per capita had significantly better health care quality indicators and lower Medicare costs. An appropriate increase in the number of generalist physicians will lead to improved quality and savings of perhaps $60 billion or more per year for the nation’s 41 million beneficiaries.
THE RATIO OF GENERALIST PHYSICIANS TO THE TOTAL PHYSICIAN WORKFORCE
Among industrialized nations, those that place a greater emphasis on generalist medicine have better health care outcomes and spend a lower percentage of GDP on health care.1 Outcomes are optimized when 40% to 50% of the total physician workforce is made up of generalist physicians. The ratio of generalist physicians to all physicians is a concept distinct from the number of generalist physicians per capita, because this ratio is a marker of the relative emphasis that a nation places upon primary care, preventive medicine, and public health. Relative to the rest of the world, the United States is poised for even higher costs and poorer outcomes. Currently, one third of US physicians are generalists. Given the rapid decrease in internal medicine residents who choose practice as generalists3 and the increasing interest in pediatric subspecialization, less than 20% of physicians who began residency in 2005 will likely practice as generalists.
THE PERSONAL MEDICAL HOME
Practice characteristics associated with improved health outcomes include first contact care, patient-focused care over time, the provision of a broad range of health services, coordinated care, family orientation, and community orientation.1 These characteristics are the foundation of the personal medical home, a term first coined by the discipline of pediatrics in 1968 and embraced by the discipline of family medicine shortly after the first reports of the Future of Family Medicine project. A system of rewards for practices that demonstrate improvements in indicators of health care quality (pay-for-performance) is currently under development by CMS. This initiative is important, but greater gains in quality and efficiency are likely to occur through the development of a pervasive system of practices that embody the characteristics of the personal medical home. In addition to payment for improvements in quality indicators, CMS should directly reward practices that demonstrate the characteristics of personal medical homes.
CHARACTERISTICS OF THE HEALTH CARE SYSTEM AND HEALTH POLICY
Health system characteristics that are associated with improved outcomes and lower costs include universal or near-universal financial assistance guaranteed by a publicly accountable body, equitable distribution of health care services with respect to regional health care needs, low or no co-payment for health care services, and comparable professional earnings by primary care physicians relative to other specialties.1 A system that provides universal access to its senior citizens can only be successful when the needs of all citizens are met in an efficient, effective manner.
SUMMARY
Family physicians and family medicine educators must become well versed in this information, and must develop personal relationships necessary to effectively deliver this message to those who make laws and policies. Our legislators and regulators must understand that policies designed to increase the number of generalist physicians will result in health care of higher quality, personal medical homes for more people, and movement toward universal access to care. They must also understand that such policies likely will result in annual savings of tens of billions of dollars for Medicare and hundreds of billions of dollars for the health care system. The return of our nation to policies that emphasize primary care, preventive medicine, and public health will lead to lower costs and improvements in quality that will be the first step to save Medicare and reform the health care system.
- © 2006 Annals of Family Medicine, Inc.
