Copernicus Healthcare Reviews

Pointing the way forward for primary care - By A.R. Strobeck Jr.

“Breaking Point: How the primary care crisis endangers the lives of Americans”

By John Geyman, M.D.
Copernicus Healthcare, 2011
Softcover, 231 pp., $18.95

Dr. John Geyman has written another tour de force on a health care topic. This time he examines the “silent crisis” which is rapidly unfolding in health care delivery: the unraveling and decline of the primary care structure.

Recognizing the flaws and limitations of the Affordable Care Act, and noting the decades-long decline in the number of primary care providers, Geyman asks: Going forward, how will patients and their families obtain medical care that is “affordable, readily accessible, continuity-based, and comprehensive”?

Assuming the ACA passes constitutional muster, millions of additional Americans will have new, limited coverage from either subsidized private insurers or Medicaid, but “Insurance without a physician — how much of a gain is that?”

Geyman divides his analysis into two parts. In Part I, he looks at the many dimensions of the crisis and its impacts on the system, particularly on patients and their families. In Part 2, he examines various policy alternatives, including lessons from other countries, and finally proposes “a comprehensive agenda for rebuilding primary care.”

Geyman believes the problem is such a challenge that its solution requires a long view, possibly over one or two generations. Successfully dealing with this problem would involve “a complete reorientation of the goals of health care, the roles of physicians and other health professionals” as well as fundamental changes in the way health care is financed. He warns that failure to do so will hasten an implosion “for much of our population, and potentially become a growing force that could bankrupt the nation.”

Geyman notes that less than one-third of U.S. physicians are practicing primary care, and “their numbers are falling fast.” Less than 20 percent of graduating U.S. medical students are selecting fields in primary care and only 7 percent are choosing family medicine. Largely because of the financial pressures associated with going to medical school, notably the heavy burden of student debt, many students are turning to specialties that they believe will be more lucrative.

At the same time, many primary care doctors have stopped seeing patients in the hospital and now confine their practice to their offices, where they are poorly reimbursed by third-party insurers. They are also experiencing higher levels of dissatisfaction with their work. Meanwhile, government policy appears to be out of touch with the magnitude of the crisis.

Yet studies show “consistent cost savings across the board in regions with most primary care physicians,” including fewer emergency room visits and hospitalizations, and a consistent increase in the quality of care in areas with a larger density of primary care doctors.

Patients are confronting greater financial barriers in accessing health care, including rising premiums and higher co-payments, deductibles and co-insurance. As for the uninsured, they are lucky to find any physician who will see them.

Patients are victimized in other ways, too. In their quest for ever greater profit, financing companies have even discovered “a highly profitable business in medical credit cards.” Interest rates can rise to 26.99 percent for G.E.’s Care Credit, and most people who obtain these cards have limited resources to begin with. They “are vulnerable to various abuses by hospitals and other providers who push these cards without transparent disclosure of their risks.”

In Part 2 of his work, Geyman looks at various policy alternatives, using key yardsticks such as accessibility, continuity of primary care, prevention, and financial neutrality in medical decision-making.

The author cites three basic policy alternatives: (1) Cede primary care to non-physicians such as nurse practitioners and physician assistants, (2) Continue our specialist dominated physician workforce; (3) Build a generalist physician workforce with primary care teams and a generalist-specialist mix of 50-50.

Geyman believes that the third choice is the obviously best course and he focuses on this solution. He views the building of a strong generalist base as the only way out of our national health care crisis.

He explains that this approach has worked well in the few areas where it has been tried, including at The Group Health Cooperative of Puget Sound, Rocky Mountain Health Plans, and the Mesa County Physicians Independent Practice Association.

At the same time, he remarks: “We cannot get to real health care reform without rebuilding our primary care infrastructure, and we can’t get that done without other fundamental system reforms — they are completely interdependent.”

Geyman takes a look at what other countries have done and how some of their experiences might be applied in the United States. He finds that we are clearly at a disadvantage: “All other countries around the world meet the challenges of access, quality, and fairness for comprehensive health care at costs that are affordable and sustainable.”

The author observes that while there is no such thing as a perfect health care system, we have much to learn from other advanced countries if we remove our ideological blinders and “give up our unfounded attitude of American exceptionalism.” We also have to give up the myths that we have the best health care and our health problems are unique to us.

Geyman looks to Ontario, Canada’s, system for an example of organized health care as “a model worth organizing and fighting for.” The Family Health Team model there has expanded the capacity of primary care through interdisciplinary teams and resolved many hitherto nettlesome problems.

The teams include family physicians, nurse practitioners, pharmacists, social workers and health educators. They provide 24/7 care, handle most of the care themselves, and are coordinators of care provided by specialists as well as from other community resources. The teams now serve 2 million people and show every sign of success.

Geyman outlines 10 “primary building blocks for rebuilding primary care in the U.S.,” including evidence-based coverage, revised physician payment, new goals and paradigm, re-design of primary care, general medical education, emphasis on ethics, expanded research, increased regulation, and malpractice liability reform. But at the foundation of the entire structure is universal coverage through a single-payer national health insurance plan, a sine qua non for the overhaul’s success.

The author views American society as divided into two Americas: “a buoyant, bailed-out Wall Street and a depressed Main Street.” i.e. it’s the 1 percent vs. the 99 percent. He discusses how corporate America has profited at the expense of sick and vulnerable Americans, and notes that even with the ACA, there is a “continuing emphasis of our market-based culture and medical-industrial complex” to turn “quick profits with little regard for the public interest.”

But Dr. Geyman has pointed a way forward.

A.R. Strobeck Jr. holds a masters in health planning and policy from the University of Illinois at Chicago as well as a masters in history from Northern Illinois University. He worked as a research associate for over 10 years for an association of health care executives.

http://www.pnhp.org/news/2012/march/pointing-the-way-forward-for-primary-care

Dr. John Geyman's new book on primary care: 'Breaking Point' - By: Wendell Potter / Firedog Lake

Just last week, the 34-nation Organization for Economic Cooperation Development (OECD) released the results of its most recent study of the health care systems in the 40 counties considered to be “developed.” It came as no surprise to see that the U.S. health care system — if we can even call it a system — is still by far the most expensive on the planet.

We spend two-and-a-half times more on health care per person than the OECD average. The average expenditure per person in the U.S. is $7,960. The OECD average, by comparison, is just $3,233. Yet we rank 29th in the number of hospital beds per person and 29th in the average length of a stay in the hospital. We have high rates of avoidable hospital admissions for people with asthma, lung disease, diabetes, hypertension and other common illnesses, and we lag behind many other countries on other measures of quality and accessibility.

And when it comes to access to physicians, we’re considerably closer to the bottom than the top. We rank 26th in the number of physicians, especially primary care doctors, per 1,000 people.

All of the bad news for the U.S. in the OECD report is troubling if not shocking, but that last data point — that 25 countries have more physicians per capita than we do — even caught me by surprise.

But after reading Dr. John Geyman’s latest book, "Breaking Point—How the Primary Care Crisis Endangers the Lives of Americans," I now understand why and how we have sunk so low. Not only does Geyman explain what has happened to our primary care infrastructure over the past several decades, he makes the most compelling case I’ve read anywhere about the urgency of rebuilding it. He also suggests ways we can do it.

If you’re not acquainted with Geyman, you should be. He is one of the wisest and most prolific writers about health care in America. "Breaking Point" is his 12th book and follows another must-read: "Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform."

As you can tell by the title of that book, Geyman is not a big fan of the Affordable Care Act, a.k.a. "Obamacare." While he notes that the reform law will expand access over the next several years, “it will not make a dent in the primary care crisis.”

In fact, he goes on, “the 32 million Americans who gain some kind of insurance coverage between now and 2019 will find it more difficult than ever to find a primary care physician. Insurance without a physician — how much of a gain is that?"

A former Republican country doctor, Geyman writes that when he graduated from medical school in 1960, there already was a growing shortage of general practitioners, but not nearly as severe as today. In 1960, 18 percent of U.S. doctors were in general practice. By 2000, the number had fallen to 12 percent, and it continues to spiral downward because of the many disincentives in the U.S. for medical students to go into primary care.

Those disincentives have led to primary care physicians becoming an endangered species.

“Specialization, subspecialization and sub-subspecialization are increasingly taking over the physician workforce,” he writes. “The reasons for these changes have much to do with money and the business of medicine. The decline in generalist medicine and primary care is inexorable with present policies in health care, and present trends signal a disaster unfolding.”

That disaster is indeed unfolding, although you’d hardly know it from the politicians and pundits who are more interested in ideology and the gamesmanship of reform than truly addressing the problems with workable solutions. And while the far-reaching reforms that are needed have so far been beyond the ability of lawmakers to enact—also having to do with money and the business of medicine—the disaster that is unfolding is increasingly being felt by American families.

Because of increases in population and the dwindling supply of general practitioners, more and more Americans are unable to find a personal primary care physician for themselves or their family. As a result, Geyman writes, their care has become increasingly expensive and fragmented.

Why does primary care matter? Geyman lists several reasons. Patients with regular access to primary care doctors receive more preventive services, and they have fewer preventable emergency room visits and hospital admissions. Because they get to know their patients well over time, primary care doctors order fewer tests than specialists, and they help protect their patients from inappropriate, unnecessary and expensive over-utilization of specialist services.

Having primary care leads to earlier diagnosis and treatment of illnesses, enhancing quality and outcomes of care. Primary care doctors are also ideally suited to coordinate care for patients who need multiple specialists. And studies have shown that patients with an ongoing relationship with a primary care doctor are more compliant with treatment.

Geyman believes, and I agree, that primary care must be at the heart of a transformed U.S. health care system — and it ultimately will be transformed because the status quo is not sustainable. And, like me, he is an optimist — transformation not only is possible, it is inevitable.

Toward the end of "Breaking Point," Geyman provides us with “ten lessons for primary care and health policy” that every reform advocate and every lawmaker truly interested in reform should read. Only someone with Geyman’s knowledge as a physician in private practice for decades and a renowned scholar of health care systems around the world could develop what essentially is a roadmap out of our unfolding disaster.

The last of those ten lessons is especially important for advocates who were disheartened and disillusioned when Congress passed the Affordable Care Act because of its shortcomings and the fact that it gives the insurance industry a renewed lease on life. Lesson #10: “The fight for sustainable and accountable health care can be a long one, but it can be won in the end by those prepared to keep at it.”

"Breaking Point" is worth reading not only to get a better understanding of the value of primary care but also Geyman’s wise counsel, reality-based optimism and challenge for us to stay in the fight and never give up. “We can all make a difference if we choose to do so,” he concludes. “Let’s go for it!”

Indeed. It’s time for all of us to rally, especially with the fate of the Senate and White House at stake.

http://fdlbooksalon.com/2011/11/27/fdl-book-salon-welcomes-john-geyman