There are so many theories out there about what we should or shouldn’t be doing with our complex and fragmented health care system. We are facing a perfect storm of factors: an aging population, a huge increase in chronic disease, new and expensive treatments, and rising expectations of what care we should be receiving. All of this is sending costs spiraling out of control. As a nation, we spend almost 3.5 trillion dollars on health care. To put that into perspective, that is more than the total GDP of every country in the world apart from China and Japan! Germany, next on the list, has an entire GDP of 3.4 trillion dollars. If the brakes are not somehow applied, spending could reach over a third of entire GDP within 30 years — a figure that would quite simply destroy the American economy. Currently, at 18 percent of the economy, we spend almost double the OECD GDP average percentage of other western nations. Yet our outcomes are nowhere near what they should be.
In 13 years of working in this health care system, my most striking fundamental observation of what needs to be done first and foremost, may sound rather simplistic, but if we are serious about improving things: Strengthen primary care and make it the backbone of American health care. In a nutshell, as someone who has experienced health care on four different continents — compared to other Western countries, our primary care system is pretty terrible. There’s a vast body of research that shows how nations with strong primary care have significantly better population health. Essentially, it all boils down to 3 elements: 1) everybody has easy access to a primary care physician; 2) better follow-up for chronic disease; and, 3) reducing utilization of more expensive services such as hospitals.
Here are three things the U.S. needs:
1. Huge national focus on primary care
This needs to happen at both a state and federal level (I am often very wary of anything “federal”), but somehow there needs to be a push from somewhere to encourage the expansion of the nation’s primary care structure. This doesn’t necessarily need to involve targets, tick boxes or regulations — but can be more about common sense measures to encourage and incentivize primary care. Hint: Falling reimbursements don’t help the situation.
2. Encourage medical students to do it
Being a primary care physician is something that sadly, very few medical students want to do. It’s considered less glamorous than going into any other field, and the pay is comparatively low. Add in hundreds of thousands of dollars of debt and the universal human desire for a nice lifestyle, and it’s easy to see why there’s a problem. This wasn’t the case a few decades ago. We need a radical rethink about how we approach this. Can we have more dedicated residency programs (this can link to federal funding), loan forgiveness (already happening in some places), and emphasizing its importance in medical school (changing the curriculum)?
3. Make it a better job
At the end of the day, this is probably the most important thing that can be done. With squeezed appointment slots, unbelievable regulatory burdens, and relatively low income — it’s a really tough job to do. And those young doctors that do go into it, quickly burn out. Primary care physicians should be pillars of their communities (like the good old days), and it should be a job that young folk immediately say: “Hey, I want to do that and serve my community.” How do we achieve this? Well, some unique and interesting models are emerging like direct primary care. However, there have to be other ways too, that can apply to underserved areas and cover those who frequently need it the most.
In my decade in clinical practice, mainly working in hospitals — one of the biggest trends I’ve seen is an inability for my patients to establish with a primary care doctor whom they can see regularly. Those that are established with an office, are frequently “flipped from doctor to doctor” during different visits. They are yearning for a good trusted physician to feel close to.
When I think to myself about the astronomical sums of money we are spending, it’s amazing that we don’t focus on getting the basics right. Take electronic health records for instance. Some reports suggest that within a couple of years, spending on health IT in the U.S. will reach $100 billion. Let me say that again: one-hundred billion dollars. The vast bulk of this growth has occurred within the last decade due to federal regulations. We also spend billions on new medicines which may only show slight benefits in quality of life.
Yet training and supplying more primary care physicians may be a fraction of this, and radically transform our health care system for the better. We are currently seeing some shortages filled by nurse practitioners (NPs) and physician assistants (PAs), and that may be one answer. However, I’d like to see significantly more primary care physicians, and make it an attractive job again. Good, traditional, regular office visits with relationship-building (and okay, whether we can also do telemedicine these days — which may be fine too). Everyone should have easy access to their doctor, with regular non-rushed appointments, with the ability for home visits particularly for the frail elderly. And yes, let’s do something about the burden of electronic medical records, which take too much time away from direct patient care, and have made the job so cumbersome and almost impossible for hundreds of thousands of good doctors across America.
So, a memo to all the folk who are losing the forest for the trees. All the policymakers, administrators, entrepreneurs, health care tech folk (if you aren’t on LinkedIn — it’s worth going on to see how many there are!), or anyone else with even a passing interest in health care: Fixing our primary care system and going back to basics is probably the single biggest thing we can do to improve health care in America.
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