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Rebuilding Primary Care: A Multifaceted Challenge

by John Geyman, MD

Our primary care system is crumbling. Primary care is unavailable to a growing part of our population, costs go up as value, quality and outcomes of care go down, and any accountability within the market-based system remains out of reach. “Reform” legislation cannot be expected to alleviate these fundamental problems, “building” as it does on our present flawed system of financing and delivering care.

Space here does not permit fleshing out the necessary steps to real system reform that would rebuild primary care. However, all or most of these approaches will inevitably be required. In their approximate order of priority, they are:
1. Adopt universal health care coverage through single-payer national health insurance. This is the only way we will ever get universal coverage so essential for optimal care of individuals and our population. It will facilitate other needed reforms by forcing new approaches to financing care.  Exploitive profiteering can be eliminated while simplification of administration can bring greater efficiency. 

2. Rethink the goals of medicine and health care. We have developed a health care system that overemphasizes the reductionist biomedical model, gives short shrift to behavioral and social aspects of illness, and all too often, continues high technology interventions to the point of futility. These are some of the steps that could help to improve the health of individuals and the population: closer collaboration between medicine and public health; increased emphasis on health promotion and disease prevention; improvement of chronic illness care; increased emphasis on mental health services; and earlier shift to palliative care when cure is not possible.

3. Change how physicians are paid. Physician payment systems are complicated and subject to being gamed for profit by many physicians and their employers. Managed care of the 1990s placed many restrictions on care in an effort to increase profits. Overvalue of many specialized and procedural services is a major factor in the decline of primary care. By contrast, primary care services, which are time-consuming, require broad clinical competence, are more cognitive and less procedural, are undervalued. Essential primary care services are best offered without cost-sharing with patients, and the wide gap between compensation of specialists and generalists must be narrowed.

4. Shift to evidence-based coverage decisions. We can no longer afford services that don’t work, are not cost-effective, or are even harmful. But our present methods of deciding on coverage and reimbursement are heavily influenced by politics, lobbying, and the interests of industry and vested medical organizations. Many new technologies are brought to market without objective assessment by disinterested experts. Other industrialized countries have developed effective ways to apply the best available clinical evidence to this decision-making process, but market forces resist such approaches in this country.

5. Re-design primary care based on generalism and interdisciplinary team practice. Given time pressures and practice complexities, many primary care physicians are burning out and not being replaced. Primary care delivery needs to be re-engineered, with primary care physicians seeing a smaller number of patients with more complex problems, working with other team members in their areas of expertise, and coordinating care by consulting specialists. 

6. Re-establish a generalist orientation in medical education. Despite the development of new education programs in medical schools and hospitals over the last three decades, specialization dominates medical education. Medical school graduates opt in droves for the increased compensation and more attractive lifestyles of non-primary care specialties. A physician workforce goal needs to be established for a 50:50 balance of generalists and specialists, together with financing changes that favor institutional change, changes in medical school admissions policies, and expanded scholarship and loan repayment programs for students and residents bound for primary care careers.

7. Create a new ethical environment of accountability in medical practice, education and research. We have a medical-industrial complex, wherein the higher the volume of services delivered, the higher the revenues to the providers and suppliers. About one-third of health care services are either inappropriate or unnecessary, some even harmful. This problem is driven by widespread conflicts-of-interest among physicians, industry, and others. And the patient is at a disadvantage in evaluating what services are, or are not, worthwhile.

8. Expand primary care and systems-oriented research. The annual budget for the National Institutes of Health (NIH), with its focus on biomedical and disease-oriented research, is about 75 times that of the Agency for Healthcare Research and Quality (AHRQ), the principal source of federal funding for primary care and systems-oriented research. Given the urgency of building a better delivery system based on primary care, we need a far greater investment in that goal.

9. Tighten regulatory processes and policies. Our regulatory apparatus is understaffed and too industry-friendly. More federal funding is needed to address these problems. An artificial hip manufactured by a Johnson & Johnson subsidiary was designed to last about 15 years, but has been failing worldwide at unusually high rates after just a few years. It was approved under lax testing requirements. The company continued marketing its defective product even after whistle-blowing efforts by orthopedic surgeons, and the U.S. still has no tracking system to monitor the experiences of those with artificial hips.

10. Increase patient- and physician-protection against medical malpractice liability. Patients need protection from medical injuries due to negligence while physicians need protection from frivolous lawsuits. But this issue is typically exaggerated as a major cause of health care inflation. Though “defensive medicine” is common, the annual costs of the medical liability system comprise only 2.4 percent of total health spending. While this issue is immensely complicated, steps to protect patients from injury and physicians from unwarranted liability for malpractice include: increased emphasis on patient safety in medical education and clinical practice; increased use of evidence-based practice guidelines as “safe harbors” for physicians; and increased use of arbitration.

Although the current political landscape is unfavorable for such forward thinking, time will probably tell that what seems utopian now is absolutely required in the future.

This piece originally appeared at on 8/31/11 and appears here on Progress Notes courtesy of Dr. Geyman.

John Geyman, MD, is Professor Emeritus of Family Medicine at the University of Washington School of Medicine in Seattle, where he served as Chairman of the Department of Family Medicine from 1976 to 1990. As a family physician with over 25 years in academic medicine, he has also practiced in rural communities for 13 years. He was the founding editor of
The Journal of Family Practice (1973 to 1990) and the editor of The Journal of the American Board of Family Practice (1990 to 2003). He has authored nine books on the health care industry.
Posted by Sonya Collins on Sep 22, 2011 10:02 AM America/New_York
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