Flatlined

Eroding Primary Care

A Typical Medicare Story

This story is a composite of many similar stories that happen every day. It illustrates both the strength of the US health care, providing unrestricted access to any doctor or treatment, and its weakness, uncoordinated medical care.

About fifteen percent of Medicare patients have diabetes. Diabetes results when the body cannot produce enough insulin or, as in the case of obesity, the tissues become resistant to its effects. Both cause high blood glucose. Diabetes is managed by injections of insulin, by oral medications that cause insulin release, and by diets that are low in sugars. Diabetes causes damage to the eyes, the kidneys, the feet, and the blood vessels. Every diabetic should receive three examinations that can help prevent or detect serious complications from diabetes: eye examinations (once each year), foot examinations (once each year), and measurement of hemoglobin A1C (every six months).(1) A1C is a blood test that is the best index of how well blood glucose is being controlled over a period of time. Measurement of blood glucose only gives the value at the moment it is measured.

Every Medicare patient should also have regular testing of blood cholesterol because, like diabetes, high cholesterol aggravates hardening of the arteries. Cholesterol can be lowered by medications and by a low-fat diet. Research is demonstrating more clearly every year that treatments to keep the levels of glucose, cholesterol, and blood pressure to near normal levels are powerful in preventing the complications of heart disease and diabetes.

Dr. Susan Greenberg was Ed Fitzsimmon’s diabetes doctor. Sometimes Ed had difficulty getting an appointment, and when he did, the waiting room was packed with fidgeting patients. Over the years Dr. Greenberg was being paid forty percent less to see fifty percent more patients. Medicare paid only $65 for a moderately complex clinic visit and paid nothing for patient education. So after covering practice overhead, paying malpractice premiums, seeing thirty-five to forty patients a day four and one-half days a week, and working sixty hours per week, Dr. Greenberg had to do more each year to maintain her income of $150,000 per year. She had not done nine years of training for such an outcome, an assembly line practice modeled on the Detroit of the 1950s.

At age fifty-five, Greenberg and her partner both became dispirited and began marking time until retirement. First they stopped taking patient calls after hours and the practice’s answering machine was turned on at 4:00 p.m. each day, weekends, and holidays to say, “If you believe you have an emergency, go to your nearest emergency room.” Most other doctors followed the same protocol, and this was one of the reasons the city’s emergency rooms were packed.

Doctor Greenberg and her many colleagues did not intend to burden the city’s emergency resources. Greenberg was worn out after thirty-five years of school, training, and practice and now in middle-age was faced with being paid less to do more. She had never thought about it before now because she liked medical practice, but her friends in business were paid more to do less as their businesses matured and they got older. They made money while they slept and she now earned less per hour she worked than she had in her youth. Many of her business friends had even been able to retire by her age and this soured her. Like taking time to educate her patients, she was not paid to take after-hours phone calls. These were courtesies, and the time for courtesies was long past.

Greenberg would spend about ten minutes with Ed Fitzsimmons. She would typically say, “Ed, your A1C is too high. I am going to increase your diabetes medicine and you need to eat less carbohydrate. Come see me in six months.” All these repetitive remarks were made as she stared down at Ed’s chart.

Ed Fitzsimmons’s cardiologist, whom Greenberg knew only casually, typically said to him, “Your cholesterol is too high so let’s increase your cholesterol medicines. You need to eat less fat. Let me see you in a year.”

But Ed never found a palatable diet, one that was low in fat to keep his cholesterol down and also low in carbohydrates for his diabetes. His glucose was never well controlled because one of the drugs that the cardiologist prescribed to lower cholesterol prevented the intestine from absorbing a drug that Greenberg prescribed to lower glucose. Both doctors, on the run, prescribed blood pressure medicine and cholesterol medication and did so without the knowledge that another physician was duplicating treatment of the same disease. None of Ed’s doctors had a holistic understanding of his history. Neither had as a goal of their management tight control of Ed’s hypertension or increased cholesterol, and the difference between a blood pressure of 130/85 and 130/95 is a fifty percent increase in risk of heart attack or stroke.(2) The seemingly small difference between a blood cholesterol of 180 and 200 milligrams per deciliter is a twenty percent increase in risk.(3) Yet Fitzsimmons’s medical management was better than the care of at least fifty percent of Medicare patients and probably equal to most of the other fifty percent.

Ed Fitzsimmons died seven years earlier than he would have had he been rigorously managed. Yet if Ed had been an adult in 1955 he would never have lived to age seventy. Doctors have powerful tools at their disposal; they could just be applied better. When the quality of primary care in the United States is considered as a system, it is mediocre to poor.

Poor Quality Care

Almost everyone has confidence in their doctor and many of us, including myself, have either been saved or delivered from a life of pain by a skilled physician. However, when US medicine is viewed as a system, it does not stack up very well on some key measures.

Over half the time in 1990-1991, Medicare patients with diabetes failed to receive at least one of three recommended tests and examinations.(4) A more depressing figure is that only fifteen percent of diabetics receive all of the recommended measures.(5) A 1994-1996 survey of Medicare patients found that less than two-thirds of those surveyed received sixteen of forty standard preventive tests, medications, or examinations when they went to the doctor. The status was better by 2001, but still not acceptable.(6) Poorly-treated high blood pressure causes stroke and heart attacks; keeping it under control with medicine reverses those risks. Almost half of patients with hypertension in the US are not treated, and only twenty-three percent are well controlled.(7)

Media attention to the problem of quality of care in clinics resounded when Dr. Elizabeth McGlynn of the Rand Corporation published a report on preventive care in the New England Journal of Medicine in 2003.(8) This report differed from others in that its purview was national and its data was obtained by starting with a random selection of patients rather than a selection of doctors’ offices which could skew the findings. Dr. McGlynn’s study incorporated all diseases, all patients and all types of preventive care in the clinic and is accepted as an accurate measure of the quality of medical practice around the country. In twelve metropolitan areas in the US, 13,000 people received only fifty-five percent of recommended care when they went to the doctor. For diabetes, hypertension, heart attacks, pneumonia, and colon cancer, it has been estimated that these findings extrapolated could account for 211,000 preventable deaths per year and over 30,000 patients with blindness or kidney failure.(9)

And the quality of medical care did not respect the source of payment. Uninsured and Medicaid patients have less access to care than Medicare and privately insured patients, but when they went to the doctor, all four groups regardless of race and economic status had about the same fifty-four to fifty-seven percent chance of getting recommended care.(10)

The US ranks last among industrialized countries on the percentage of low birth weight infants and infant mortality, but I never knew whether that was just the lack of insurance or also the effect of poverty.(11) When infant mortality was examined among states in the US, an increase of only one primary care doctor per ten thousand population was associated with a 2.5 percent reduction in infant mortality and in low birth weight. (12) Poverty is a hard thing to fix, but there is strong evidence from several studies that in the US access to primary care mitigates the effects of poverty on health of patients of all ages.(13), (14) Irrespective of other factors, the US looks bad on international comparisons of deaths from diseases that are preventable or treatable by primary care such as asthma, pneumonia, and cardiovascular disease even when adjusted for the effects of factors such as wealth and smoking. The US mortality rate from thirty-four such diseases was sixteenth among nineteen industrialized countries whereas Canada ranked fourth. (15), (16)

A Shrinking Primary Care Workforce

The reasons for this abysmal performance are related to the decline in access to and payment for primary care in the United States. The two categories of medical doctors are primary care doctors and specialists. Primary care is usually provided by family practitioners, pediatricians, and general internists, although specialists can and often do act as primary care doctors if the patient’s major problem is their specialty. Primary care has three goals:

  1. Preventing people from crossing the line from health to disease and then developing chronic conditions
  2. Managing chronic diseases once they develop in order to prevent flare-ups
  3. Diagnosing and treating short-term illnesses before they become severe.

Measures to prevent chronic disease may be as simple as immunizations and encouraging weight loss, or they may be more complex like control of elevated cholesterol and blood pressure.

The other kind of medical care is specialty care, where services are provided by specialists such as cardiologists, gastroenterologists, and surgeons. These specialties all have one thing in common— their practitioners perform procedures and are paid very well for performing them.

Exactly how many primary care doctors are needed to care for a large population of patients is determined by how medicine is practiced. If there is no interest in disease prevention then not so many are needed. The Kaiser Permanente prepaid group practice is primary-care based and focuses on prevention. Half of Kaiser’s physicians have been generalists. (17) On average, though, specialists comprise sixty-five percent of the physician workforce, generalists only thirty-five percent, a proportion that has steadily declined from fifty percent in the 1960s.(18)

Not only has the proportion of doctors practicing primary care decreased but also the number of graduates of US medical schools choosing it. In 1998, fifty percent of US graduates picked primary care; this declined to forty percent in 2004. Graduates of foreign medical schools now make up over sixty percent of family practitioners in training though they comprise only twenty percent of physicians entering practice.(19)(20)(21)

The Devaluation of Primary Care

Primary care is a shrinking workforce because it has become devalued. The two factors that are responsible are: the fee for service payment system and the disconnection of the public from a physician accountable for their care.

Doctors are paid directly by insurers or by government programs for each service that they render, and they are paid separately from hospitals. A group at Harvard University years ago developed a payment system called the Relative Value Scale that is used by the Medicare program and by almost all insurers to determine physician fees. Each of the thousands of services that doctors may provide is assigned a numerical level of difficulty for performance of that service by the Relative Value Scale. The American Medical Association regularly updates the scale. The performance of procedures is always assigned a greater number on the Relative Value Scale than management of a patient’s health because the fee-for-service payment system pays based upon the level of difficulty of the service not the value of the service.

For example, Medicare in Houston in 2005 paid a primary care doctor $53 for a routine office visit, and a doctor can only see so many patients in one day. Specialists have a much better financial arrangement. A primary care doctor who diagnoses a breast cancer is paid for a routine office visit while the specialist who removes the cancer is paid in Houston $1,234 for the hour-long operation. A gastroenterologist is paid $464 for a colonoscopy which takes fifteen to thirty minutes (recommended every five years in people over fifty years to detect colon cancer); a neurosurgeon $3,651 for a complex brain surgery which takes three to four hours; a cardiologist $1,555 for a four-vessel cardiac catheter procedure; and a cardiovascular surgeon $ 2,154 for a four-vessel heart bypass operation. Specialists’ incomes are, therefore, two to five-fold greater than generalists for equivalent hours worked. Primary care doctors must see 30 or more patients per day to keep their incomes up, which is likely the reason that so many patients do not receive all the medical treatments and education that they need—there is not time.

The other reason is lack of accountability of one physician for a patient’s care. Was it Dr. Greenberg or the cardiologist who was responsible for the management of Ed Fitzsimmon’s cholesterol? Neither was. The second reason that primary care is in decline in the United States is because primary c are doctors cannot practice the kind of medicine that they were trained to and want to. Despite the relative shortage of primary care physicians, the average Medicare patient sees two primary care doctors and five specialists, none of whom likely has any idea what the other is doing.(22) Fee-for-service medicine lends itself to fragmented medical practice because nothing about it rewards systems of patient management that produce good outcomes. Just as Ed Fitzsimmons was not well served by bouncing from doctor to doctor, that kind of medical practice is not fulfilling to primary care physicians. They know that their value to the patient is marginal. None of the parties win.

The decline of primary care leaves the United States without the most essential element that it needs to improve the value of health care—a primary care workforce. We will not see improved value in health care until every American anchors them self to one primary care doctor who coordinates care, educates the patient, and is the first point of contact with the medical system.

  1. “If You Have Diabetes. . . Know Your Blood Sugar Numbers,” NIH Publication 98-4350. National Diabetes Education Program. July 2005.
  2. S. MacMahon, R. Peto, J. Cutler, et al., “Blood Pressure, Stroke, and Coronary Heart Disease. Part 1, Prolonged Differences in Blood Pressure: Prospective Observational Studies Corrected for the Regression Dilution Bias,” Lancet 335, no. 8692 (March 31,1990): 765-764.
  3. Steven Haffner, “Rationale for New American Diabetes Association Guidelines: Are National Cholesterol Education Program Goals Adequate for the Patient with Diabetes Mellitus?” American Journal of Cardiology 96, no. 4A (August 22, 2005): 33E-36E.
  4. Jonathan P. Weiner, Stephen T. Parente, Deborah W. Garnick, et al., “Variation in Office-Based Quality. A Claims-Based Profile of Care Provided to Medicare Patients with Diabetes,” JAMA 273, no. 19 (May 17, 1995): 1503-1508.
  5. Louis H. Diamond, MD, personal communication with author.
  6. Stephen F. Jencks, Edwin D. Huff, Timothy Cuerdon, “Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998-1999 to 2000-2001,” JAMA 289, no. 20 (May 28, 2002): 305-312.
  7. David J. Hyman and Valory N. Pavlik, “Characteristics of Patients with Uncontrolled Hypertension in the United States,” New England Journal of Medicine 345, no. 7 (August 16, 2001): 479-486.
  8. Elizabeth A. McGlynn, Steven M. Asch, John Adams, et al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine 348, no. 26 (June 26, 2003): 2635-2645.
  9. “The First National Report Card on Quality of Health Care in America,” Rand Health Research Highlights, 2004. Accessed online 2007: http://www.rand.org/pubs/research_briefs/RB9053-1/RB9053-1.pdf
  10. Steven M. Asch, Eve A. Kerr, Joan Keesey, et al., “Who Is at Greatest Risk for Receiving Poor-Quality Health Care?” New England Journal of Medicine 354, no. 11 (March 16, 2006): 1147-1156.
  11. Barbara Starfield, “Is US Health Really the Best in the World?” JAMA 284, no. 4 (July 26, 2000): 483-485.
  12. Leiyu Shi, James Macinko, Barbara Starfield, et al., “Primary Care, Infant Mortality, and Low Birth Weight in the States of the USA,” Journal of Epidemiology and Community Health 58 (2003): 374-380.
  13. Leiyu Shi, Barbara Starfield, Bryan Kennedy, et al., “Income Inequality, Primary Care, and Health Indicators,” Journal of Family Practice (April 1999): 275-284.
  14. Leiyu Shi and Barbara Starfield, “The Effect of Primary Care Physician Supply and Income Inequality on Mortality among Blacks and Whites in US Metropolitan Areas,” American Journal of Public Health 91, no. 8 (August 2001): 1246-1250.
  15. Elllen Nolte and Martin McKee, “Measuring the Health of Nations: Analysis of Mortality Amenable to Health Care,” BMJ 327 (November 15, 2003).
  16. James Mackinko, Barbara Starfield, Leiyu Shi, “The Contribution of Primary Care Systems to Health Outcomes within OECD Countries, 1970-1998,” Health Services Research 38, no. 3 (June 2003).
  17. Jonathan P. Weiner, “Forecasting the Effects of Health Reform on US Physician Workforce Requirement. Evidence from HMO Staffing Patterns,” JAMA 272, no. 3 (July 20, 1994): 222-230.
  18. Robert L. Phillips, Marty S. Dodo, Larry A.Green, “Adding More Specialists Is Not Likely to Improve Population Health: Is Anybody Listening?” Health Affairs Web Exclusive, March 15, 2005.
  19. Mark D. Schwartz, William T. Basco, Michael R. Grey, et al., “Rekindling Student Interest in Generalist Careers,” Annals of Internal Medicine142 (April 19, 2005): 715-724.
  20. “Who Filled First-Year Family Medicine Residency Positions from 1991-2004?” Graham Center One-Pager, American Family Physician Vol. 72. No. 3, August 1, 2005.
  21. Jordan J. Cohen, AAMC Reporter: April, 2005. A Word from the President: “Filling the Workforce Gap,” accessed at www. aamc.org/newsroom/reporter/april05/word.htm.
  22. Hoangmai H. Pham,, Deborah Schrag, Ann S. O’Malley, Beny Wu, and Peter B. Bach, Care Patterns in Medicare and Their Implications for Pay for Performance, New England Journal of Medicine 2007;356:1130-9.