I once asked my primary care physician why she had opted out of a specialty. She answered "...because I want to focus on the well being of an individual not just one part of them. " PCPs have the opportunity to treat minor illness's and detect/prevent future complications. Strong communication between PCPs and patients is important because it allows the patient to receive more information on their health and the benefits of prevention. The prupose of having a regular check up is to monitor and control an individuals health. If any abnormality is detected that is when a referral is made. Primary care should be made mandatory for everyone. Sadly this is not the case and every day more people are going to the emergency room with complications that could have been prevented.
A relationship between PCPs and patients is essential, and in the end allows for the patient to have control over their own health. Once this line of communication is open, it is easier to inform patients on healthier living, preventive measures to implement in their houshold. Fostering this idea that a PCP is not just someone you go to when you catch a cold. Teach patients the importance of physicals and yearly checkups. Implement more programs where the patient feels more in control of their health. Making their health and well being a collaborative effort between the PCP and the patient.
At times PCPs can seem as an obstacle for many patients that do need to see a specialist. It especially is harder when referrals seem to take forever. I dont feel that PCPs should be blamed for this, its just the system that seems to lack efficiency. I do believe that more work is needed in this area. PCPs should not be an obstacle, and not necessarily a gate keeper but more of a guide that facilitates.
Wednesday, September 17, 2008
In order to have a successful system, all levels of services need to be on the same page when it comes to patient care. This would require that all levels of services develop a common goal like providing the best care to all people in that health system. In reality, different services have their own goals. Primary care services might look to see as many patients in a day as possible, and specialty care might look to see less patients but patients with more serious health problems.
I think that every level of service that comes in contact with a patient should take a couple of minutes to get to know the basic lifestyle of the individual. It should not be left to the primary care physician; it should also be the job of specialty doctors. Patients need to have a close relationship with their doctors, otherwise they will not be able to disclose important information that can be necessary to make an accurate diagnosis. At the same time, primary care physicians have to deal with the bulk of the problem, which is to get all the information out of the patient and get to real issue.
I agree with other systems that put more emphasis on primary care doctors because they are the ones that have to decide whether the individuals needs a referral, treatment, or to "wait out" the problem. At the same time, primary care physicians should not become an obstacle when an individual wants to or requires to see a specialty doctor this is why developing a similar goal is such an important step to forming a successful health system.
I think that every level of service that comes in contact with a patient should take a couple of minutes to get to know the basic lifestyle of the individual. It should not be left to the primary care physician; it should also be the job of specialty doctors. Patients need to have a close relationship with their doctors, otherwise they will not be able to disclose important information that can be necessary to make an accurate diagnosis. At the same time, primary care physicians have to deal with the bulk of the problem, which is to get all the information out of the patient and get to real issue.
I agree with other systems that put more emphasis on primary care doctors because they are the ones that have to decide whether the individuals needs a referral, treatment, or to "wait out" the problem. At the same time, primary care physicians should not become an obstacle when an individual wants to or requires to see a specialty doctor this is why developing a similar goal is such an important step to forming a successful health system.
Tuesday, September 16, 2008
We are Ready
The issue of primary care is a very interesting one in both the public and the private sector of health care systems. In the private U.S system we have companies which provide immediate specialty care to patients, companies such as Blue Cross and Aetna. When paying their higher premiums, some plans allow you to access specialty care immediately or spend minutes with a general practitioner in order to get a referral. Other companies such as Keiser allow you to pay a lower general premium than the other companies; however they put a higher emphasis on the use of GP’s and a full consultation with a primary care physician or “gate keeper” is always required, and specialty referrals are difficult to come by.
To understand whether the American people are interested in seeing a “gate keeper,” we can turn to the customer satisfaction statistics available through JD power [http://www.jdpower.com/healthcare/ratings/health-plan-ratings/california]. Here one can actually see that Americans (in California at least) were most satisfied with a system in which GP’s were employed to reduce costs. I am not sure what the customer satisfaction was due to, but low costs would be my immediate guess. Now that we have established that Americans are ready for a primary care system, let’s analyze further.
It is my personal belief that we should adopt a nationalized health care system or at least a system in which the government guarantees that every citizen has a basic level of health care provided for him or her. In terms of primary care, there are two countries with polar opposite philosophies in terms of primary care - Japan and the U.K.
Japan has a system that has eliminated primary care for the most part. The population is extremely satisfied with the level of care, the longevity of the Japanese are at record highs, but the finances of this Japanese system are in the red. In the U.K, gate keepers are used to keep costs low and satisfaction and longevity are still quite high. With this information in mind, I think it would make both practical and cultural sense for the U.S to adopt a higher level of primary care in order to bring costs down. For ethical reasons, I think we need to make health care the government’s responsibility.
To understand whether the American people are interested in seeing a “gate keeper,” we can turn to the customer satisfaction statistics available through JD power [http://www.jdpower.com/healthcare/ratings/health-plan-ratings/california]. Here one can actually see that Americans (in California at least) were most satisfied with a system in which GP’s were employed to reduce costs. I am not sure what the customer satisfaction was due to, but low costs would be my immediate guess. Now that we have established that Americans are ready for a primary care system, let’s analyze further.
It is my personal belief that we should adopt a nationalized health care system or at least a system in which the government guarantees that every citizen has a basic level of health care provided for him or her. In terms of primary care, there are two countries with polar opposite philosophies in terms of primary care - Japan and the U.K.
Japan has a system that has eliminated primary care for the most part. The population is extremely satisfied with the level of care, the longevity of the Japanese are at record highs, but the finances of this Japanese system are in the red. In the U.K, gate keepers are used to keep costs low and satisfaction and longevity are still quite high. With this information in mind, I think it would make both practical and cultural sense for the U.S to adopt a higher level of primary care in order to bring costs down. For ethical reasons, I think we need to make health care the government’s responsibility.
On another note, Massachusetts (arguably the state with the most progressive health care system) has just passed legislation to strengthen its own primary care system [http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine/20080813masslegislation.html].
Somebody Make Primary Care Sexier Quick!!!
What went wrong? How come doctors get paid a lot for doing surgical procedures, but not much for sitting with patients, trying to diagnose what is wrong with them and coming up with the right treatment for them? If universal healthcare is far beyond our reach at this point…and we have to work within this corrupted system, then we need to find a way to repair primary care as best as possible because this is an area that could make a big difference in the quality of care we receive. Primary care is like the backbone of the nation’s health care system…and will collapse unless some changes are made. There are a few primary care models that I’ve been researching. One of them is the “medical home” with the basic idea being that everyone should have a relationship with a doctor who both treats the patient and, in conjunction with a team, helps the patient navigate the health-care system (which is definitely valuable in this complex mess of a health care system we have right now). Right now, primary care practitioners don’t get paid to help patients navigate the system (coordinating visits to specialists, for example). Maybe these kinds of payments could make primary care sexier for med school students. Another model is where patients see more of “non-physician clinicians and staff” (basically advanced practice nurses, physicians assistants, etc). The physicians manage the team and provide direct care for patients who have more complex medical problems, and oversee the nurses who treat the healthier patients. I’m skeptical about this because I am not sure that nurses and Pas can diagnose patients as well as doctors can. The last model is my least favorite, but provides the best care…the type of care everyone should be receiving already with the amount of money we are spending. In the last model people who can afford it will pay anywhere between a few hundred and a few thousand dollars a year to the doctor on top of their insurance, and get the kind of attentive care and easy access we all want. One online source says that with this concierge model, “you will get an hour long physical, preventative and nutrition counseling, thorough evaluation of problems, a cell phone number for out of hours access, an advocate who can meet you in the ER in case of a dire emergency and champion your case during necessary specialty care. A house call can also be accommodated if you are unable to leave home. Prescriptions will be called in or electronically sent in directly to you pharmacy minimizing the chance of error. You will never have less than 30 minutes with you doctor and he/she will refer you only when a joint decision is made that it is absolutely necessary.”—now that’s the kind of health care I want!!…why can’t we get that without going broke?
Primary Care
There is no doubt that an effective and concrete health care system needs to have a strong primary care system. Starfield states that "primary care is the crucial foundation of a health care system" in her book entitled "Primary care: balancing health needs, services, and technology." From the articles in the reading for this week as well as many other studies conducted on the effectiveness of primary care, the same conclusion is reached: health care systems that have a strong primary care system foster healthier patients, ultimately leading to a lower mortality rate and overall higher life expectancy. I would advocate for a 50-30-20 breakdown of primary care, specialty services, and hospital services, respectively. Having the majority of our health care system focused on primary care will allow patients to become more proactive about their own health. I also think that primary care physicians should also include preventive care in their services, which will aide in reducing unnecessary health care costs. With a constant and effective primary care system, patients will be healthier overall, which will then reduce the use of specialty care services. As others have previously stated, it is important to increase the "attractiveness" of becoming a primary care physician so more medical students go into general practice. With most of medical school graduates going into specialty care, there are not enough doctors to become primary care physicians--which is the first pitfall of the US primary health care system. In order to counter this problem, there should be some kind of incentive to become a general practitioner. On the other hand, because developed countries face more chronic disease, specialty care is also very crucial to the overall health care system, which is I believe that 30% of health care should be focused on it. In conclusion, primary care provides the backbone of a country's health care sytem and without it, the health of the people is taken care of by doctors that barely know patients. When a patient has a primary care physician that he/she sees regularly, the patient tends to be more healthier and if disease does arise, it is usually caught very early on--and if needed, the PCP can direct their patient to a specialist. A strong communication between the PCP and specialist is also important because the PCP has the patient's medical history (including previous treatments, allergies, etc) which can help prevent any medical mistakes. The US health care system definately needs major reform, especially in the realm of its primary health care. However, many citizens do not like the idea of a PCP or gate-keeper and it is our duty, as public health professionals, to help change the way the people of the US think about health care.
PCPs & Foreign Medical Graduates
Though it is nearly impossible to quantify, primary health care should be the dominant form of health care services that a person receives in his lifetime. Primary health care consists of preventive medicine, which leads to overall better health outcomes. Furthermore, I argue that for the average person suffering ailments, care from a general practitioner will more often than not suffice. In other words, during a person’s lifetime, most of his medical needs can be taken care of by a GP, who will be able to refer him to a specialist if need be.
As discussed in the Macinko article, primary care is correlated with better health outcomes. And since American primary care providers are in such short supply, more investment must be put into ensuring adequate supply of doctors for the future. Speaking from personal experience, the medical school admissions process is extremely competitive. And rightly so. I am not suggesting any alteration in medical school admissions criteria. Rather, alterations must be made to allow for more spots for prospective medical students. As Yahaira suggested, many very qualified applicants are rejected from U.S. medical schools. Some go on to study in foreign institutions and eventually return to the U.S. to train and practice.
Given the dearth of doctors graduating from American medical schools, drastic changes in U.S. medical education are called for. A first step would be to expand the class sizes of current medical schools. Another, albeit more long-term, step would be to create more medical schools. This potential endeavor is worthy of public attention—and funding.
The child of foreign-trained medical professionals, I find my global health advocacy side at odds with my I’m-happy-to-be-an-American side. As discussed in the Starfield report, the U.S. relies heavily on foreign medical graduates to fill PCP positions, correlating with poorer health outcomes in these doctors’ home countries. While I do believe it is unethical for the U.S. to continue to rely on foreign medical graduates, much of the solution lies in these doctors’ home countries. Can we really blame a foreign medical graduate from a developing country for wishing to greatly improve his/her lot in life and that of family by moving to a developed nation? On an individual level, most people would say no. Unfortunately, on a broader level, the mass migration of medical professionals away from developing countries wreaks havoc on already-fragile health systems.
There are few personal incentives to keep medical professionals of developing countries at home. This is no secret within these countries. Take, for example, what I saw when I lived in the Philippines for one year (2005-2006). I worked in rural villages and urban shantytowns in great need of medical services. Now juxtapose this with all too prevalent nursing school advertisements, boasting their ability to place graduates in foreign (first-world) hospitals. And even more egregious—accelerated nursing programs specifically designed for MDs who wish to immigrate to developed countries where nurses are in high demand.
Clearly, the need for PCPs in the U.S. is a problem that must be addressed immediately—not only for the people of this country, but also for people all over the world, particularly in countries from which our foreign medical graduates originate.
As discussed in the Macinko article, primary care is correlated with better health outcomes. And since American primary care providers are in such short supply, more investment must be put into ensuring adequate supply of doctors for the future. Speaking from personal experience, the medical school admissions process is extremely competitive. And rightly so. I am not suggesting any alteration in medical school admissions criteria. Rather, alterations must be made to allow for more spots for prospective medical students. As Yahaira suggested, many very qualified applicants are rejected from U.S. medical schools. Some go on to study in foreign institutions and eventually return to the U.S. to train and practice.
Given the dearth of doctors graduating from American medical schools, drastic changes in U.S. medical education are called for. A first step would be to expand the class sizes of current medical schools. Another, albeit more long-term, step would be to create more medical schools. This potential endeavor is worthy of public attention—and funding.
The child of foreign-trained medical professionals, I find my global health advocacy side at odds with my I’m-happy-to-be-an-American side. As discussed in the Starfield report, the U.S. relies heavily on foreign medical graduates to fill PCP positions, correlating with poorer health outcomes in these doctors’ home countries. While I do believe it is unethical for the U.S. to continue to rely on foreign medical graduates, much of the solution lies in these doctors’ home countries. Can we really blame a foreign medical graduate from a developing country for wishing to greatly improve his/her lot in life and that of family by moving to a developed nation? On an individual level, most people would say no. Unfortunately, on a broader level, the mass migration of medical professionals away from developing countries wreaks havoc on already-fragile health systems.
There are few personal incentives to keep medical professionals of developing countries at home. This is no secret within these countries. Take, for example, what I saw when I lived in the Philippines for one year (2005-2006). I worked in rural villages and urban shantytowns in great need of medical services. Now juxtapose this with all too prevalent nursing school advertisements, boasting their ability to place graduates in foreign (first-world) hospitals. And even more egregious—accelerated nursing programs specifically designed for MDs who wish to immigrate to developed countries where nurses are in high demand.
Clearly, the need for PCPs in the U.S. is a problem that must be addressed immediately—not only for the people of this country, but also for people all over the world, particularly in countries from which our foreign medical graduates originate.
Quiet Revolution
The health care system in US has a quiet revolution going on in the past three decades. More and more medical students desire to enter into medical specialties. The standard medical schooling is considered just basic and specialty is in high demands. Among young doctors, there is a trend or possibly pressure to advance oneself among the peers for more prestigious and lucrative specialist training. A more realistic estimate would be 40% primary care, 30% specialty care and 30% for hospital care in the landscape of US care system. The house calls from family physicians will be a thing of the past. As the shrinking population of providers dedicated to general practice becomes medical reality, the system needs to face and adjust to this change.
Though many considered this is "wrong" and worrisome. Personally I think this might not be a bad thing since nature itself having the ability to modulate the supplies. In the 21st century, we have an educated population and many channels of health information. More people are becoming health literate and seek treatments in an informed manner. In the 19th century and even 20th century, we do not have the educated mass and limited channels of getting informed on health issues. People now turn on TV, search Internet and read pamphlets to obtain health information and most have the reading and critical thinking ability. In the informed society, the primary care physicians may not play such important roles as before. Though many studies have shown the cost benefits of primary care, I think we need to re-think the roles and functions of primary care physicians in the post modern era. In several industrialized Asian countries, patients are allowed to see specialists and costs are low compared to the United States. The question states that studies have shown the cost benefits of access to primary cares, but do these studies consider the overall pictures of health care? If we look only at the saturated emergency rooms in cosmopolitan areas in US cities, then primary care would proved to be more cost effective and beneficial. However, when we consider the entire landscape of US health care, we might draw different conclusions. Most patients visit emergency rooms for common medical problems are uninsured, underinsured or illegal immigrants. If we have the universal health care in place, this phenomenon will disappear gradually. And this is more of a social issue rather than medical issue. When it comes to the right mix of medical practice, we need to ask other questions ? What kind of diseases American people have in the 21st century? What type of training and technology we need in responding to these illness? In what way can we most effectively and economically respond to the challenges of these popular modern diseases? Possibly the specialized approach and alternative approach are more in demands and can offer more for the US patients. We will always need the primary care physicians but the roles would be changed given the shift of modern lifestyle. Our thinking and study designs need to address these issues from the context of a post modern era. P.S. the reason I raise the percentage of hospital care is because of
the lager aging population and longivity. As the life expectancy increases and baby boomers age with a large number, the hospital usage will increase according to the demographic changes.
Though many considered this is "wrong" and worrisome. Personally I think this might not be a bad thing since nature itself having the ability to modulate the supplies. In the 21st century, we have an educated population and many channels of health information. More people are becoming health literate and seek treatments in an informed manner. In the 19th century and even 20th century, we do not have the educated mass and limited channels of getting informed on health issues. People now turn on TV, search Internet and read pamphlets to obtain health information and most have the reading and critical thinking ability. In the informed society, the primary care physicians may not play such important roles as before. Though many studies have shown the cost benefits of primary care, I think we need to re-think the roles and functions of primary care physicians in the post modern era. In several industrialized Asian countries, patients are allowed to see specialists and costs are low compared to the United States. The question states that studies have shown the cost benefits of access to primary cares, but do these studies consider the overall pictures of health care? If we look only at the saturated emergency rooms in cosmopolitan areas in US cities, then primary care would proved to be more cost effective and beneficial. However, when we consider the entire landscape of US health care, we might draw different conclusions. Most patients visit emergency rooms for common medical problems are uninsured, underinsured or illegal immigrants. If we have the universal health care in place, this phenomenon will disappear gradually. And this is more of a social issue rather than medical issue. When it comes to the right mix of medical practice, we need to ask other questions ? What kind of diseases American people have in the 21st century? What type of training and technology we need in responding to these illness? In what way can we most effectively and economically respond to the challenges of these popular modern diseases? Possibly the specialized approach and alternative approach are more in demands and can offer more for the US patients. We will always need the primary care physicians but the roles would be changed given the shift of modern lifestyle. Our thinking and study designs need to address these issues from the context of a post modern era. P.S. the reason I raise the percentage of hospital care is because of
the lager aging population and longivity. As the life expectancy increases and baby boomers age with a large number, the hospital usage will increase according to the demographic changes.
The Right Mix
Obviously, primary care is essential to a well-functioning and effective healthcare system. However there must be a delicate balance between primary care, specialty care, and services provided through a hospital since not one functions well without the other components. Although I am not sure that this balance can be easily assigned numbers that will truly match the need, I would advocate for a system comprised of 45-35-20.
In other words, primary care should be the major component of a healthcare system, accounting for 45% of services rendered. A primary care physician can best filter through the cases in need of specialty care. This aspect should account for a total of 35%, and the remaining 20% should be hospital services. The majority of people need simple primary care, thus a majority over the other two categories. Although some people would argue that 45% for primary care is not enough of a majority, I am taking several factors into account in my estimation. First, the people who truly need only primary care visit the physician much less frequently than those needing specialty care. This is due to the simple fact that most people whom require specialty care need extensive follow up visits. Also, many people that do not receive specialty care simply do not ever receive medical attention because they feel they are too healthy to visit a doctor only for wellness visits.
Similarly, the amount of specialty care should be higher than the hospital services for two reasons: 1) A portion of those people requiring specialty care can be taken care of outside of a hospital setting. 2) Many patients that receive hospital services can be triaged and stabilized, then sent home with a schedule of follow-up procedures from a specialty care physician. Therefore, not only will this ratio of 45-35-20 help keep specialty care costs to a minimum, it will allow for the allocation resources to best improve the overall health of a nation.
How bout' 'em Health Care?
Primary care has been the go to player like Terrell Owens last Monday Night, when needed to have cost containment and efficiency. Even though winning covers all the facade of unity and cracks, it only takes one game to lose it all, and reform is needed. Which is why I am swayed to more primary care, but I am not a conservative running attack. I am an aggressive air it out spread passing attack offensive mind, so bring in hospital services and a bootleg dose of specialty care. True, a balance of these three will lead to higher quality and possible better equity, but efficiency is what I am aiming. It is not efficient to run the same play on every down in the game, that is why US is one of the few countries in the gutter like San Diego Chargers. Having a strong hospital services will lead to better last minute game winning drives, but it’s the mixture of primary care and specialty care that set up the winning drive. There needs to be a better usage in terms of consistently plays from primary care in cooperation with specialty care. The specialists need to be able to rely and trust that the GIs will help preventive side in addition to referring to them. Overall, the game plan should be strong hospital services and I am okay with having a mediocre primary care and specialty care as long as they are on the same team.
song of the blog: I got to put a shout out to Ne-Yo on getting me to listen to New Kids on the Block.
NKOTB and Ne-Yo: Single
The Need For More Basic Care
The issue lies within getting the culture of health care to change. The disdain that medical students/physicians have for the primary care physician must be addressed somehow. Family care physicians must receive more regard for the work they do.
Arvantes, James. Health Care Experts Describe the Benefits of Primary Care. AAFP, 2007. http://www.aafp.org/online/en/home/publications/news/news-now/professional-issues/20070611pcforum.html
Balance of Care
While actual percentages or numbers are arbitrary, I would generally agree with the 50/25/25 approach of primary, specialty, and hospital services, respectively. However, a stronger primary care system seems to be a proven benefit to public health, regardless of the actual values. Astoundingly, in one study described in the International Journal of Health Services, an increase in primary care physicians contributed to everything from improved “all-cause” health outcomes to decreases in low birth weights, higher patient satisfaction, and even lower mortality rates. In fact, they provided evidence that showed “an increase of one primary care physician per 10,000 population was associated with an average mortality reduction of 5.3%...” If nothing else, primary care acts as a necessary gatekeeper to the seemingly more desirable specialty care, which would be an ineffective and inefficient first line of defense.
Additionally, I thought that was a very good point made about the mindset of the current medical environment. It caused me to realize of all the conversations I have had with friends or acquaintances pursuing a career in medicine, I cannot recall a single person who expressed an interest in being a primary care physician. I personally considered going to medical school and the one question I remember being asked most often was “What do you want to specialize in?” It appears as if it is almost inconceivable that someone would actually seek to remain in primary care! According to a number of journal articles, the interest in primary care careers has dropped from 36% in 1982 to 14% in 1995, 8% in 2005, and finally to 2% in 2008 (a thank-you to Ramon for the most current percentage). Currently more than ¾ of all internal medicine residents migrate away from primary care.
The income disparity (specialists make, on average, nearly 2.5 times more) and re-imbursement rate (insurers tend to reimburse an average of 170% more for specialty services) seems to be the most frequently documented reason for this drastic and ever-increasing shift. However, I also came across other perks to specialization including a tendency for more predictable work hours and greater prestige among colleagues. With so much stacked against primary care it seems, both figuratively and literally, like choosing the Ford Taurus over the Aston Martin.
Sources:
Macinko J, Starfield B, Shil L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37(1):111-26. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/17436988
Zajicek G. Benefits of primary care. Nature. 194 Aug 18;370(6490):501http://www.nature.com/nature/journal/v371/n6498/pdf/371552a0.pdf
Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. 2007;146:301-306. http://www.annals.org/cgi/reprint/146/4/301.pdf
Shil L. Balancing primary versus specialty care. J R Soc Med. 1995;88:428-432. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1295294&blobtype=pdf
Why go into primary care?
I had a conversation with a couple of my good friends who are both currently in medical school...I asked one of them what kind of doctor he wants to be and he replied, "I think I want to be a surgeon." As a result of his answer, I jumped right into what I learned from PM508 about the shortage of primary care physicians and how the US health care system fosters an environment that discourages medical graduates from pursuing careers in primary care. His response, again apathetic to my passionate discourse, was that primary care just seemed "too boring." In the conversation with my other friend, she says she wants to specialize in radiology because that's where the money is. In the back of my mind, I can't help thinking, are these the doctors we will be trusting our lives to? Why is there such a disconnect between passionate doctors who would do anything for their patients to those who just want to lead an exciting life with all the perks that life has to offer? Is that what medicine has turned into? A profession based on business and prestige rather than to serve the sick?
Dr. Dean Ornish wrote a piece on this very topic, the primary care crisis and steps needed to improve the number of medical graduates practicing primary care. Here's the link: http://www.newsweek.com/id/158429/page/2
Also, USA Today reported from JAMA that only 2% of US medical school graduates commit to the field of primary care, as seen here:
http://www.usatoday.com/news/health/2008-09-09-doctor-shortage_N.htm?loc=interstitialskip
I am not saying that specialists are evil or spite them for their choices. All I'm saying is that medical schools and the entire health care system alike encourage medical students' choices in favor of specializing. And though I don't think increasing primary care physicians' pay would solve their internal motivations to go into primary care, I do believe it will ease the financial burdens amassed from student loan debt. Let's focus on getting the population healthy on a more comprehensive level, as the WHO defined health, a state of physical, mental and emotional well-being and not just the absence of illness.
Dr. Dean Ornish wrote a piece on this very topic, the primary care crisis and steps needed to improve the number of medical graduates practicing primary care. Here's the link: http://www.newsweek.com/id/158429/page/2
Also, USA Today reported from JAMA that only 2% of US medical school graduates commit to the field of primary care, as seen here:
http://www.usatoday.com/news/health/2008-09-09-doctor-shortage_N.htm?loc=interstitialskip
I am not saying that specialists are evil or spite them for their choices. All I'm saying is that medical schools and the entire health care system alike encourage medical students' choices in favor of specializing. And though I don't think increasing primary care physicians' pay would solve their internal motivations to go into primary care, I do believe it will ease the financial burdens amassed from student loan debt. Let's focus on getting the population healthy on a more comprehensive level, as the WHO defined health, a state of physical, mental and emotional well-being and not just the absence of illness.
Monday, September 15, 2008
health care workforce
The ideal mix should be 50% primary care, 25% specialty care and 25% hospital services. These numbers are ambiguous and based on following reasons.
Primary care costs less compare to seeing specialists or getting hospital services, and gives much better population health outcome. This has been pointed out by Barbara Starfield in “Is US Health Really the Best in the World?” 5 out of 7 nations in the top health ranking have strong primary care, which translate into better access to care. Though there is no record on the influence of specialty physician-to-primary care physician, “relatively superficial analyses suggest that the reverse may be the case (Starfield).” Primary health care includes general practitioners, health educators, health promotion and disease prevention services. On the other hand, specialty physicians focus on treatment with a specific specialized area of medicine, and demands high payment. Primary care physicians are more interactive with patient's overall health history. They are the main source of educators to good health behavior change in patients. In addition to general treatment, the level of intervention with primary care physicans in promoting health can result in much better population overall outcome. Therefore, primary care deserve larger potion of the mix system.
Specialty care and hospital services share equal weight in the system because hospital care relies on specialists and technologies. Specialty and hospital care should not be considered for lower proportion because they are part of the indicators of quality care in health systems. In the article, “It’s the Prices, Stupid: Why the US is so different from Other Countries,” Gerard Anderson stated that the overall health quality depends on the readily accessibility of health care to everyone in the society. The accessibility is associated with the availability of health resources, such as health workforce and productive services. When patients need medical attention, they should have adequate medical practitioners attend to them. With the focus on individuals, special care and hospital services can ensure prolonged life and thus improve the quality of life.
There are limitations on these distributions. Strong statistical data shows that the costs to health care can largely affect equal access to health care and effective allocation of resources, thus resulting on low quality of health care system. For example, Japan is second to US in available technology but still ranks the 1st among OECD countries, where US ranks 13th (Starfield). Canada ranks in the top 5 while their density in acute care hospital bed is more than US. When considering the amount of spending on health care based on GDP, Japan spends 7.8% of GDP and Canada spends 9.1% of GDP, where US spend 13.0% of GDP (Anderson). This shows that US is putting more financial investment but not getting deserved benefit on overall health. This indicates efficiency in allocation of resources and different dynamic of health provision.
Strictly looking at the workforce, to lower the cost of health care and maintaining the need of specialists and hospital cares, the ideal mix of system should be with majority in primary care and equal share between specialists and hospital cares.
Primary care costs less compare to seeing specialists or getting hospital services, and gives much better population health outcome. This has been pointed out by Barbara Starfield in “Is US Health Really the Best in the World?” 5 out of 7 nations in the top health ranking have strong primary care, which translate into better access to care. Though there is no record on the influence of specialty physician-to-primary care physician, “relatively superficial analyses suggest that the reverse may be the case (Starfield).” Primary health care includes general practitioners, health educators, health promotion and disease prevention services. On the other hand, specialty physicians focus on treatment with a specific specialized area of medicine, and demands high payment. Primary care physicians are more interactive with patient's overall health history. They are the main source of educators to good health behavior change in patients. In addition to general treatment, the level of intervention with primary care physicans in promoting health can result in much better population overall outcome. Therefore, primary care deserve larger potion of the mix system.
Specialty care and hospital services share equal weight in the system because hospital care relies on specialists and technologies. Specialty and hospital care should not be considered for lower proportion because they are part of the indicators of quality care in health systems. In the article, “It’s the Prices, Stupid: Why the US is so different from Other Countries,” Gerard Anderson stated that the overall health quality depends on the readily accessibility of health care to everyone in the society. The accessibility is associated with the availability of health resources, such as health workforce and productive services. When patients need medical attention, they should have adequate medical practitioners attend to them. With the focus on individuals, special care and hospital services can ensure prolonged life and thus improve the quality of life.
There are limitations on these distributions. Strong statistical data shows that the costs to health care can largely affect equal access to health care and effective allocation of resources, thus resulting on low quality of health care system. For example, Japan is second to US in available technology but still ranks the 1st among OECD countries, where US ranks 13th (Starfield). Canada ranks in the top 5 while their density in acute care hospital bed is more than US. When considering the amount of spending on health care based on GDP, Japan spends 7.8% of GDP and Canada spends 9.1% of GDP, where US spend 13.0% of GDP (Anderson). This shows that US is putting more financial investment but not getting deserved benefit on overall health. This indicates efficiency in allocation of resources and different dynamic of health provision.
Strictly looking at the workforce, to lower the cost of health care and maintaining the need of specialists and hospital cares, the ideal mix of system should be with majority in primary care and equal share between specialists and hospital cares.
PHC
As the textbook states, health policy goals try to accomplish: Equity/access; quality; and cost-containment. These goals are shaped and challenged by cultural, political, and institutional contexts. With regard to quality, there lies the difficulty in implementing an objective definition. With regard to cost-containment, the overall challenge is maintaining quality under restrictive budgets.
I also agree on the text’s indication that basic level of care should consist of only primary care and not high-tech, in order to contain costs, ensure universal coverage, and assure quality care.
Inevitably, within the US, the clear barriers toward equitable provisions and utilization of multi-tiered services are contingent upon the very fabric of our market-based society; such that, (as stated in Ch. 4): all decisions made by consumer; the consumer must know value of goods; and, the consumers must pay full cost and receive full value.
To discuss the distribution of equitable primary, secondary and tertiary care (or, the prevalence of one type of care over the other), we must consider rationing. Since, even with the equitable allocation of funds and resources to the varying type of care, there will still exist rationing at the micro-allocation level. Furthermore, the difference between health care and medical care adds to the difficulties of proper promotion of health. While the former tries to restore the capacity for integrative functioning, the latter restores physiological and psychological functioning.
Having said that, with regard to which type of care should be given more priority (or, even equitable consideration across the board), we must discuss the clear distinction made between benefits and necessities to further attack the problem of rationing. In other words, are all procedures, surgeries, and services which seem beneficial also considered necessary? Ultimately, there are three types of need. The normative needs are ones that the medical experts (physicians) deem significant. The felt needs are ones that the person feels he needs them (i.e., he wants or desires it). And, the expressed needs are when the felt needs are actually taken into action (i.e., they are placed on waiting lists). (Culyer, 1997).
Another approach is to give scarce resources based upon a priority system where individuals who have most to gain as compared to their pre-operative state, should be awarded the help.
Coming back to the principle of equality, does this mean that people should have equal chances for the best treatments? Apparently this can’t be the case since there aren’t unlimited resources. As a result, it would be that people have the same rights to receive services of the same quality. But, the problem becomes, how can we measure the quality of the different treatments used for different illnesses? It would be hard to categorize such illnesses and deciphering their quality of treatments.
Since personal needs are subjective, and, by focusing on medical needs (which are still representing arbitrary good and ill health bestowed upon the patients), the fact that we would be restoring a patient’s normal range of opportunities (since every person at least has the right for “human functioning” even if not “optimal”) shouldn’t be overridden by the need to gain more QALYs by the patient who is “better off.”
Taking everything into consideration, I do agree that there is a need for the equitable provision of a multi-tiered program of services, targeting various stages of health and medical care needs. There shouldn’t be an overemphasis of one form of care over another, since they are all inter-dependent determinants of health outcomes. It is a matter of whether or not the distribution of equitably allocated resources will be just, or unjust.
Culyer, A.J. Being Reasonable About The Economics of Health. Lyme: Edward Elgar, 1997.
I also agree on the text’s indication that basic level of care should consist of only primary care and not high-tech, in order to contain costs, ensure universal coverage, and assure quality care.
Inevitably, within the US, the clear barriers toward equitable provisions and utilization of multi-tiered services are contingent upon the very fabric of our market-based society; such that, (as stated in Ch. 4): all decisions made by consumer; the consumer must know value of goods; and, the consumers must pay full cost and receive full value.
To discuss the distribution of equitable primary, secondary and tertiary care (or, the prevalence of one type of care over the other), we must consider rationing. Since, even with the equitable allocation of funds and resources to the varying type of care, there will still exist rationing at the micro-allocation level. Furthermore, the difference between health care and medical care adds to the difficulties of proper promotion of health. While the former tries to restore the capacity for integrative functioning, the latter restores physiological and psychological functioning.
Having said that, with regard to which type of care should be given more priority (or, even equitable consideration across the board), we must discuss the clear distinction made between benefits and necessities to further attack the problem of rationing. In other words, are all procedures, surgeries, and services which seem beneficial also considered necessary? Ultimately, there are three types of need. The normative needs are ones that the medical experts (physicians) deem significant. The felt needs are ones that the person feels he needs them (i.e., he wants or desires it). And, the expressed needs are when the felt needs are actually taken into action (i.e., they are placed on waiting lists). (Culyer, 1997).
Another approach is to give scarce resources based upon a priority system where individuals who have most to gain as compared to their pre-operative state, should be awarded the help.
Coming back to the principle of equality, does this mean that people should have equal chances for the best treatments? Apparently this can’t be the case since there aren’t unlimited resources. As a result, it would be that people have the same rights to receive services of the same quality. But, the problem becomes, how can we measure the quality of the different treatments used for different illnesses? It would be hard to categorize such illnesses and deciphering their quality of treatments.
Since personal needs are subjective, and, by focusing on medical needs (which are still representing arbitrary good and ill health bestowed upon the patients), the fact that we would be restoring a patient’s normal range of opportunities (since every person at least has the right for “human functioning” even if not “optimal”) shouldn’t be overridden by the need to gain more QALYs by the patient who is “better off.”
Taking everything into consideration, I do agree that there is a need for the equitable provision of a multi-tiered program of services, targeting various stages of health and medical care needs. There shouldn’t be an overemphasis of one form of care over another, since they are all inter-dependent determinants of health outcomes. It is a matter of whether or not the distribution of equitably allocated resources will be just, or unjust.
Culyer, A.J. Being Reasonable About The Economics of Health. Lyme: Edward Elgar, 1997.
The Contribution of Primary Care Systems to Health Outcomes and Costs
I am a strong advocate of primary care. Agreeing with Yahaira, fostering a strong relationship with your PCP is pertinent to your overall health. By seeing a PCP consistently, different aspects of health (physical, social, mental, and emotional) can be more easily monitored. Taking a more holistic approach to medicine, we would hope for more health individuals, thus a more healthy and productive society.
As argued in this week's reading(http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12822915), primary care has been shown to have a positive influence on health costs, appropriateness of care, and outcomes for the most common medical problems. Many countries have strengthened their primary care systems in an effort to control costs by using primary care as a gatekeeping system. These efforts have proved successful in some countries in lowering health care costs. But despite being organized and adequately funded, it is important to ensure that a primary care system in a country is also equitable and quality care to the population. While I'm a big proponent of a strong primary care system in the US, I believe there is definitely need for improvement in affordability, access, and equity of care.
At the same time, it is also important for the US to consider ethical implications when recruiting primary care physicians. I found the reading on the recruitment of physicians from developing countries to the primary care supply in the US a topic for debate(http://www.annfammed.org/cgi/content/full/5/6/486). Not only should the US be concerned about the health of their own population, but they do have an ethical obligation to not contribute to the health deprivation in poorer countries by becoming dependent on foreign physicians. This issue must also be addressed when looking to improve the primary care system in the US.
As argued in this week's reading(http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=12822915), primary care has been shown to have a positive influence on health costs, appropriateness of care, and outcomes for the most common medical problems. Many countries have strengthened their primary care systems in an effort to control costs by using primary care as a gatekeeping system. These efforts have proved successful in some countries in lowering health care costs. But despite being organized and adequately funded, it is important to ensure that a primary care system in a country is also equitable and quality care to the population. While I'm a big proponent of a strong primary care system in the US, I believe there is definitely need for improvement in affordability, access, and equity of care.
At the same time, it is also important for the US to consider ethical implications when recruiting primary care physicians. I found the reading on the recruitment of physicians from developing countries to the primary care supply in the US a topic for debate(http://www.annfammed.org/cgi/content/full/5/6/486). Not only should the US be concerned about the health of their own population, but they do have an ethical obligation to not contribute to the health deprivation in poorer countries by becoming dependent on foreign physicians. This issue must also be addressed when looking to improve the primary care system in the US.
Primary Care
I am personally a huge advocate for primary care. I undertand that forcing patients toward gate-keeper may elongate their care a little, i think that it is vital for primary care physicians to be aware of what is going on with their patients. Forcing patients to visit PCPs will also foster a relationship between doctor and patient, which can also lead to positive health outcomes. This relationship can foster more communication of preventive measures. I feel that the only way for patients to truly understand their care and health needs, a relationship with a PCP is a must.
I also understand the need for hospital services, but think then the ER should act as a gatekeeper. I think that if a patient comes into the ER with an urgent problem, they should be sent to a specialist from there. I dont think patients should waste their time trying to contact their PCP, when in the end they may be shuttled over to the ER anyway.
This then leads to the discussion of the supply of PCPs. It is not right that we keep depleting countries of their physicians to supplement our 31% of PCPs. We need to re-evaluate our med school admission process. Most students rejected from US med school turn to foreign school and then return to practice in the states. If they are good enough to be doctors then why did they get rejected in the first place. Perhaps schools can offer alternative programs for PCP, so students would get admitted only if they were looking to practice primary care.
I also understand the need for hospital services, but think then the ER should act as a gatekeeper. I think that if a patient comes into the ER with an urgent problem, they should be sent to a specialist from there. I dont think patients should waste their time trying to contact their PCP, when in the end they may be shuttled over to the ER anyway.
This then leads to the discussion of the supply of PCPs. It is not right that we keep depleting countries of their physicians to supplement our 31% of PCPs. We need to re-evaluate our med school admission process. Most students rejected from US med school turn to foreign school and then return to practice in the states. If they are good enough to be doctors then why did they get rejected in the first place. Perhaps schools can offer alternative programs for PCP, so students would get admitted only if they were looking to practice primary care.
A Healthy Balance
While, in theory, I understand how a robust primary care system would be more cost effective to not only the individual, but the society as well, there tend to be faults to the system, at least in the United States, that need to be addressed before we can rely on primary care entirely to help lower health care costs. Overall, if you have a system where individuals are less likely to pay exorbitant out of pocket expenses, that individual is more likely to seek preventative medical care, thereby increasing his/her own health status. This idea is appealing, however, it’s not this simple.
Primary care aims to improve the functioning of the overall health system by promoting prevention, better referral and coordination of health care, and finally, continuity of care. Starfield, Macinko, and Shi suggest in this week’s reading that the United States enjoyed slight improvement of our primary care system from the years 1970 to 1998, mainly due to participation in HMO plans. This benefit may be obsolete considering that pariticpation in HMO plans has decreased since the 1990’s (91.6 million in 1996 as compared to 66.8 million in 2007, http://www.statehealthfacts.kff.org/profileind.jsp?rgn=1&ind=348&cat=7), mainly due to decreased access to care and physician disapproval of HMOs. In April 2007, legislation aimed to require some of the Illinois medicaid patients to enroll in HMOs had physicians fuming (http://www.chicagotribune.com/business/chi-thu_notebook_0823aug23,0,495722.story). This and other examples show that physicians are still not ready to relinquish the reins to health maintenance organizations just yet.
Speaking from personal experience, I found the HMO plan to be extremely inefficient. While I understand that the gatekeeping method may be necessary for people who tend to crowd specialists’ offices for common ailments, if you happen to injure your knee, for example, and it takes 3 months to figure out what is wrong, well, that simply seems unreasonable. It seems that while the idea of gatekeeping and better coordination of care is appealing, I don’t think that we’ve quite perfected this in the US. I didn’t feel that my physicians were talking to each other at all throughout my experience, hence the coordination of care seemed to be lacking. With regards to referrals, I had to wait, what seemed like an unnecessary amount of time to see my PCP, just to hear that I had to see a specialist. RIGHT. I think that I knew that before.
Furthermore, we simply don't have the resources to promote primary care as the main source of health care in the states. This is evident by the simple fact that only 31% of US-trained physicians go into primary care, as compared to 69% of subspecialists (Starfield B, Fryer G. The Primary Care Physician Workforce: Ethical and Policy Implications). It is also suggested that foreign physicians help maintain our pool of PCPs. This would be fine if it didn't mean that we were depleting those countries of their own resources. Thinking about this, in order to maintain a healthy primary care system, shouldn't the United States encourage their own MDs to go into general medicine, perhaps through incentives, salary increases, etc.?
Taking all of this into consideration, until we are able to increase the quality of primary, managed care, and provide adequate resources for it, there needs to be a healthy balance of primary, specialty, and hospital care.
Primary care aims to improve the functioning of the overall health system by promoting prevention, better referral and coordination of health care, and finally, continuity of care. Starfield, Macinko, and Shi suggest in this week’s reading that the United States enjoyed slight improvement of our primary care system from the years 1970 to 1998, mainly due to participation in HMO plans. This benefit may be obsolete considering that pariticpation in HMO plans has decreased since the 1990’s (91.6 million in 1996 as compared to 66.8 million in 2007, http://www.statehealthfacts.kff.org/profileind.jsp?rgn=1&ind=348&cat=7), mainly due to decreased access to care and physician disapproval of HMOs. In April 2007, legislation aimed to require some of the Illinois medicaid patients to enroll in HMOs had physicians fuming (http://www.chicagotribune.com/business/chi-thu_notebook_0823aug23,0,495722.story). This and other examples show that physicians are still not ready to relinquish the reins to health maintenance organizations just yet.
Speaking from personal experience, I found the HMO plan to be extremely inefficient. While I understand that the gatekeeping method may be necessary for people who tend to crowd specialists’ offices for common ailments, if you happen to injure your knee, for example, and it takes 3 months to figure out what is wrong, well, that simply seems unreasonable. It seems that while the idea of gatekeeping and better coordination of care is appealing, I don’t think that we’ve quite perfected this in the US. I didn’t feel that my physicians were talking to each other at all throughout my experience, hence the coordination of care seemed to be lacking. With regards to referrals, I had to wait, what seemed like an unnecessary amount of time to see my PCP, just to hear that I had to see a specialist. RIGHT. I think that I knew that before.
Furthermore, we simply don't have the resources to promote primary care as the main source of health care in the states. This is evident by the simple fact that only 31% of US-trained physicians go into primary care, as compared to 69% of subspecialists (Starfield B, Fryer G. The Primary Care Physician Workforce: Ethical and Policy Implications). It is also suggested that foreign physicians help maintain our pool of PCPs. This would be fine if it didn't mean that we were depleting those countries of their own resources. Thinking about this, in order to maintain a healthy primary care system, shouldn't the United States encourage their own MDs to go into general medicine, perhaps through incentives, salary increases, etc.?
Taking all of this into consideration, until we are able to increase the quality of primary, managed care, and provide adequate resources for it, there needs to be a healthy balance of primary, specialty, and hospital care.
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