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Saving primary care medicine, the foundation of a rational health care system

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The collapse of primary care medicine has been in the news for several years, and the problem is getting worse. Recently, only 2 percent of today's medical students indicated they wanted to go into primary care. Training programs in primary care are closing. Two hospitals in Phoenix in the past month have indicated they would no longer train family physicians. Most residency positions in general internal medicine and family medicine are filled with doctors educated in other countries.

Yet primary care is the foundation of any rational health care system. Studies have shown that the overall health of a population depends more on primary care than the number of specialists. Preventive medicine and common health problems are best treated in primary care, saving the more serious and unusual problems for specialists.

If not physicians, who will fill the gap in primary care? Nurses have stepped up and created programs to train primary care nurse practitioners (NPs). Physician assistants (PAs) have emerged and are providing primary care in many settings. However, NPs and PAs work best when they work with physicians as "physician extenders." When NPs and PAs work alone in primary care, quality may suffer and the efficiency of treating most problems at the primary care level is lost. NPs and PAs are part of the solution in primary care, but there remains a critical need for primary care physicians.

The history of primary care medicine has several ups and downs over the past 50 years. Prior to and after World War II, most physicians were general practitioners (GPs). The 1960s saw the first "age of specialization," and very few medical students became GPs. In 1969, a new specialty, family practice, was born, and there was a resurgence in the 1970s as FPs replaced GPs as the new breed of family doctor.

FPs experienced a decline in the 1980s similar to today, as high-tech medicine began to flourish and many specialist incomes became much greater than those of FPs and general internists. Internal medicine is the largest specialty in medicine, yet in the 1980s and today the great majority of internists subspecialize into fields that have higher incomes, such as cardiology, gastroenterology and dermatology.

FPs and general internists made a comeback in the 1990s with the beginning of managed care (HMOs). HMOs looked at FPs and general internists as "gatekeepers" and realized lower health care costs if everyone had to be seen by a primary care physician (PCP) before being allowed to see a specialist. PCPs are FPs, general internists or pediatricians for children.

Americans were not happy being forced to always get their care through a PCP, and managed care declined in the late 1990s as HMOs opened up direct access to specialists. The Preferred Provider Organization (PPO) has become the most popular insurance model, where people may choose primary care or specialty physicians in an organized network of physicians agreeing to accept discounted rates for their services.

The current decline in primary care has now lasted a decade, and a critical shortage of primary care physicians is looming. Starting salaries in primary care are going up, but there are not enough physicians coming out of the pipeline to fill open positions. Something needs to happen to rescue primary care medicine.

The American population is aging, and chronic health problems such as hypertension, diabetes, heart disease and even obesity eat up most health care costs and cause the most serious problems, like heart attacks and heart failure. Chronic health problems are best treated early by primary care physicians. A new model of chronic illness care has emerged based on a team of health professionals engaging with a population of patients, but the primary care physician is critical as the director of this team.

The medical home model has emerged to improve health care and increase its efficiency by lowering costs while at the same time increasing the quality of care. When greater resources are placed into prevention and managing chronic problems, the overall costs of care go down as the rates of major problems decline. Recent evidence has shown a decline in heart attacks in a population through a reduction in cigarette smoking -- still the most common cause of heart disease and cancer. When a population of diabetics is better controlled, the costs of care go down as there are fewer complications of the disease, such as kidney failure, heart attacks, loss of vision and amputations of limbs.

The medical home uses a team approach to care with information systems that help all the professionals coordinate care with informed and activated patients. Electronic health records (EHRs) allow for a flow of information where all the caregivers have the same information to work from, and best practice clinical guidelines are imbedded in the patient information. With emerging personal health records (PHRs), patients are able to get involved in their own care much like people today are able to get involved with their money and travel management.

Medicare and other health insurance plans are seriously considering a major change in the financing of health care to support the growth of the medical home model. Rather than traditional fee-for-service practice that only rewards physicians for doing things, payment would be made for the coordination of care by the physician and team. The medical home payment would incentivize the team to reach out and coordinate care in ways that do not require patient visits, such as over the telephone and through secure online communication. Quality outcomes of care to populations become the new financial incentive.

Will the medical home model cause a resurgence in interest in primary care among today's medical students? It is too early to tell. But the buzz has captured national attention, and support for the medical home is likely to be a part of the Obama administration's health care reforms. There is a critical need to lower health care costs, and the efficiencies of the medical home offer a way to do this and improve the health of the population.

Scherger, M.D., M.P.H., is chair of the San Diego County Medical Society Communications Committee and editor of San Diego Physician magazine.

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