We need less medical care, not more. We need more preventive services and more patient education, not more high-technology crisis care. Specifically, we need more primary care physicians.
Most informed citizens are aware that in the U.S., per capita expenditures on health care are the highest in the world. Each American spends an average of $8100 per year, representing a substantial proportion of annual income. The total U.S. health care burden of $2.5 trillion (in 2009) is 17.6% of our gross domestic product.
These numbers need to come down, but costs continue to rise. A long-term solution is available, one that doesn't involve structural changes in how health care services are bought and paid for. [Such structural change is critically important, but vested interests continue to severely dominate the U.S. political landscape.] The specific long-term solution involves focusing on primary care.
Among the many benefits of effective delivery of primary care are comprehensiveness of care, quality and efficiency of care, and health equity.1 These benefits have been demonstrated worldwide, in developing as well as developed nations. In 14 countries with gross annual incomes of less than $10,000 per capita, moving to comprehensive primary care resulted in much lower under-five mortality rates. Countries such as Sri Lanka and Costa Rica that have made political commitments to both primary care services and education are achieving relatively high life expectancies despite low per capita incomes.2 [Costa Rica, for example, ranks number 30 in life expectancy. The U.S. ranks number 36.]
Access to primary care physicians (PCPs) impacts patient's health and well-being across the board. Statistical analyses regarding numerous key indicators of population health are startling. In U.S. metropolitan areas, an increase of one PCP per 10,000 decreases inpatient admissions by 6%, decreases surgeries by more than 7%, and decreases emergency room visits by 10%.3 Beyond this, an increase to 100 PCPs per 100,000 people would save close to $600 million annually.4 As of 2006, there were approximately 80 PCPs per 100,000 persons in New York City.
Increased availability to PCPs leads directly to reduced utilization of medical services, specifically, reduced referrals to specialists and decreased use of hospital care.5 These savings apply across a broad range of patient presentations. In Canada, patients with multiple chronic diseases required less hospitalizations and less specialist use owing to enhanced availability of primary care services.6
The extensive benefits of primary care availability and utilization are well-documented. Worldwide, a shift is underway positioning primary care in the forefront of health care delivery. In the United States, we need to provide a political, educational, and financial environment in which similar sea changes can take place.
1Kringos DS, et al: The breadth of primary care. A systematic literature review of its core dimensions. BMC Health Serv Res 10:65, 2010
2Cleland J: The benefits of educating women. Lancet 376:933-934, 2010
3Kravet SJ: Health care utilization and the proportion of primary care physicians. Am J Med 121(2):142-148, 2008
4Chetty VK, et al: FPs lower hospital readmission rates and costs. Am Fam Physician 83(9):1054, 2011
5Sirovich B, et al: Discretionary decision making by primary care physicians and the cost of U.S. Health care. Health Aff 27(3):813-823, 2008
6Hollander M, et al: Increasing value for money in the Canadian healthcare system: new findings and the case for integrated care for seniors. Healthc Q 12(1):38:47, 2009
The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.
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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.