Pointing the way forward for primary care

By A.R. Strobeck Jr.
March 21, 2012

“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.

PNHP note: “Breaking Point” by Dr. John Geyman, past president of Physicians for a National Health Program, is available at PNHP’s store at the special price of $10 with free shipping. You can purchase the book here and you can review other books by Dr. Geyman and other authors at the PNHP store site.