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The Decline Of Primary Care: The Silent Crisis Undermining U.S. Health Care

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Amidst all the crises confronting our country today -- ranging from the deficit, rising unemployment and underemployment, mistrust of legislators and the government -- there is another major crisis: the continued deterioration of primary care that threatens to break up the very foundation of U.S. health care. Underreported and widely misunderstood, the continued decline of primary care results in uncontrollable inflation of health care costs, decreased access to necessary care, increasing fragmentation and depersonalization of care, and unacceptable quality and outcomes of care. As health care costs spiral out of sight and consume an ever-increasing part of the country's GDP, this trend, unless reversed, can destabilize and eventually bankrupt our health care system, and perhaps even our country.

This is the first in a series of five posts that will describe this crisis, how it has progressed over the last 50 years despite all attempts to deal with it, together with why it matters to all Americans and what can be done about it. These posts are drawn in part from my latest book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans, just released by Copernicus-Healthcare and soon to appear as an ebook on Amazon.

Primary care is a term that many are unfamiliar with, often even including within the health professions. We're talking here about generalist physicians and other health professionals working with them, in the ongoing care of unselected (not referred) patients of all ages for whatever problems they need to seek care. This is in the front lines of health care, for individuals and families, in their own community setting. General practitioners in earlier years represented this kind of physician. Since the 1960s, four other kinds of generalist physicians have evolved as various kinds of medical education programs have been developed -- family practice (now family medicine), general internal medicine (for adults), general pediatrics (for children), and osteopathic physicians (with training that includes manipulative therapies).

Most advanced countries have at least 50 percent of their physicians as generalists at the foundation of their health care systems. While the U.S. had such a base until World War II, that number has declined over the last 60 years to less than 30 percent. And that number is dropping fast. Less than one in five U.S. medical graduates are now entering a primary care specialty, while most opt for better-paying, more attractive lifestyles of other specialties. (Pear, R. Doctor shortage proves obstacle to Obama goals. New York Times, April 27, 2010: A1) We now have a specialist-dominated system without anywhere near the number of generalists needed.

In his recent article in the New Yorker, Dr. Atul Gawande, general and endocrine surgeon at Harvard Medical School, described the importance of the generalist in these compelling terms:

"Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country's best electrician on the job (he trained at Harvard, somebody tells you) isn't going to solve this problem. Nor will changing the person who writes him the check." (2) (Gawande, A. The cost conundrum: What a Texas town can teach us about healthcare. The New Yorker, June 9, 2009: 34-44.)

Advanced countries around the world with higher-performing health care systems than the U.S. have all build their systems on a solid base of primary, generalist care, readily available to patients for common health care problems where they live. Secondary care includes more specialized care for less common problems, while tertiary care deals with rare or unusual medical problems in university medical centers or other large urban hospitals. In most of those countries, specialists serve as consultants for particular medical problems, while primary care physicians provide ongoing continuity of care for all of their patients' problems.

This is how a 2008 report of the General Accounting Office sums up the primary care crisis in this country:

"Health professional workforce projections that are mostly silent on the future supply of and demand for primary care services are symptomatic of an ongoing decline in the nation's financial support for primary care medicine. Ample research in recent years concludes that the nation's over reliance on specialty services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care -- all hallmarks of primary care medicine -- can achieve better health outcomes and cost savings. Despite these findings, the nation's current financing mechanisms result in an atomized and uncoordinated system of care that rewards expensive procedure-based services while undervaluing primary care services." (GAO. Primary Care Professionals: Recent Supply Trends, Projections and Valuation of Services. Washington, D.C. GAO-08-4721. Government Accounting Office, February 2008, p 15)

In our next post, we will see how our upside-down system does not work, and how it is responsible in large part for most of our system problems, whether at the level of individual health care or population-based care.