Over view for the health system and

the primary care practice in the United States

Ahmed M. Rashad

Basic Facts About U.S. Health Care System

Most expensive in the world Technology is key driver Insurance coverage is often linked to employment For most, insurance coverage is voluntary More than 45 million Americans are uninsured Spend more per capita (almost $6,000) and a higher % of GDP (about 15%) on health care than every other industrialized country

U.S. Health Care System is very complex

Government

Out of Pocket Payments Providers

Premiums Employer Insurance

U. S. Health Insurance Coverage 2000

8.30% 13.3%

10.3%

64.1% 14.0%

Employer Medicaid

Private Insurance Uninsured

Medicare

Where Does US Spending Come From (2003)

11.0% 16.0% 33.0%

36.0%
Pvt. Ins. Out-of-Pocket State

4.0%
Federal Other

Per Capita Growth In Health Care Expenditures 1970-2001

(Trendline calculated for period 1970 1997)
1600 1400 1200 1000 800 600 400 200 0
19 70 19 72 19 74 19 76 19 78 19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02

Primary Care Physicians

Definition
the provision of integrated, accessible health care services by clinicians that are accountable for addressing large majority of personal healthcare needs, developing sustained partnership with patients, and practicing in the context of family and community.
It has been addresses by the WHO since the 1940s as a policy to achieve universal affordable medical coverage.

Who is practicing primary healthcare in the US

50% 40% 30% 20% 10% 0% Family Internal Pediatrics Ob & Gyn Doctor Medicine Series1

High demand for the Primary Care Practice in the US

About 15%, of the American population are uninsured. about 20% lacking the usual healthcare services due to the double digit rise in the health insurance premiums. Weak infrastructure and adequacy of health force is uncertain. Healthcare system is highly fragmented. Poor quality Raising complain about the disparities in healthcare services is a dangerous issues.

Qualitative Demand
Primary Care Practice can provide, if well designed, a comprehensive solution for most of these problems. Strong primary care infrastructure can provide equitable cost-effective health care as it can reach to the low income groups of the community and support them with the basic medical care. Primary care base healthcare delivery system has the ability to improve quality while reducing cost.

Quantitative Demand
The Primary Care Physician (PCP) in the United States needs 10.6 hours per day to deliver the recommended care for chronic patients, plus 7.4 hours per day to provide preventive care to an average panel of 2500 patient which is less than the mean US panel size by about 800 patients About 80 million patients are in need for the PCP to get his/her permission for the laboratory, radiology, and specialist services. Thirty three percent of patients failed to have an appointment with their PCP in 2003 raised from 23% in 1997.

The Perceived Market Need

Primary care practice in the US is evolving as a result of market pressure and not due to structural governmental activities

The development of Managed Care Organization during the 90s and the need for the primary care doctor gate keeper function. Decreasing job satisfaction and the increase in the educational debit and salary disparity, create a strong sense that becoming a primary care doctor a strange errand.

Not attractive specialty

Medical Students do not like to work as a Primary Care Physicians The percentage of the US medical school graduates entering the primary care field dropped to 38% in 2006 from 50% in 1998. The percentage of the 3rd year residents in internal medicine planning to become primary physicians dropped from 54% to 27% for the same period. Specialties portion increased from 32% to 38%; primary care portion declined by 3% from 1995 to 2003. Number of US medical students entering family practice reduced by 50% between 1997 and 2005 and 80% of physicians enters it in 1998 became sub specialists or hospitalists.

Not attractive specialty

Percent Change between 1998 and 2006 in the Percentage of U.S. Medical School Graduates Filling Residency Positions in Various Specialties . Data are from the National Resident Matching Program .

Underlying causes of the problem

No serious proposals to narrow the gap between primary care physicians and specialties are on the national agenda Primary care physician is the lowest earning in the United States among other medical specialties. Medicare increased rates for doctors by 13% from 1995 to 2003 while the inflation rate was 21% for the same period. Private payment and Medicaid even has lagged more than this. Physicians salaries has been declined by average 7% after adjusting to inflation and primary care doctors income reduced by 10.2% .

Underpaid Specialty

Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005

Underpaid Specialty

Underlying causes of the problem

Number of satisfied PC doctors reduced by 12% from 1991 to 1996

High workload Unsatisfying academic image is important contributing factors. Primary Care Practice is not viewed as high niche specialty and not appreciated in medical academic field compared to other specialties. Medical students spent most of their life times as excellent highly ranked students and it is not easy to assume that their personal trait accept to continue the rest of their lives working in a low ranked profession.

How the US address the problem:

should include actions on both the primary care practice side (microsystem improvement) and the healthcare system side (macro system-reform).

The Futures of Family Medicine (FFM) project

FFM project proposed new model for family practice (FP) characterized by
Patient-centered team approach Elimination of barriers to access Including an electronic health record More functional offices Focus on quality and outcomes Enhancing practice finance.

The Futures of Family Medicine (FFM) project

5 challenges for the future of this practice:
Promoting a broad more accurate understanding of the specialty among the public Identifying areas for commonality in a specialty whose strength is the wide scope and locally adapted practice type Winning the academic respect for this specialty Making the FP a more attractive career option Addressing the publics perception that the FP is not solidly grounded in science and technology

The Futures of Family Medicine (FFM) project Comments

It is the comprehensive management of the problem the high complexity in both design and implementation may make them more theoretical than practical solutions. It does not give direct solution for the low income problems. It also provides a kind of national project for policy reform.

Innovations in organizing the primary care provision

like Primary care teams; advanced access; the chronic care model; collaborative care; Group medical visits are proactive moves from the PCP representative bodies. Quality of care and creating what is called best of times are core values for these innovations, which are aiming at reduce the workload and increase satisfaction of the primary care doctors.

Developing Hospitalists subspecialty

one of the approaches has been taken to improve the satisfaction and decrease work load over the primary care doctors through carrying out the function of taking care of the admitted primary care patients.

Recommendations