The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.
-Paul Starr, The Social Transformation of American Medicine, 1984
How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidencecompellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require a approach that appreciates and leverages power in ways that are different than in the past.
But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value, and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care’s foundational role in US health care and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.
The consequences have been withering constraints that have diminished primary care’s value, and that have thwarted its roles as first line manager of most medical conditions, and as patient-advocate and guide for downstream services. Combined with fee-for-service reimbursement and a lack of cost/quality transparency, primary care’s waning influence has precipitated a cascade of impacts, allowing health industry revenues to grow at more than four times the general inflation rate for more than a decade, with unnecessary utilization and cost that credible estimates suggest is half or more of all health care spending.
These impacts have been catastrophic not only for primary care physicians, but for patients, who are routinely exposed to unnecessary medical risks, and for purchasers, who for decades have borne an unnecessarily onerous economic burden. It seems unlikely that these groups’ prospects can improve without a meaningful change in the strategy pursued by primary care’s leading organizations.
The state of primary care
Primary care is a demoralized medical specialty. Recent Medscape data show that, on average, generalists make about half what their specialist colleagues do. Other surveys are more pronounced. A 2010 Graham Center study calculated a $3.5 million career income difference between primary care and specialist physicians.
None of this is lost on medical students. Faced with skyrocketing training debt, few now opt to make significantly less, so the percentage selecting primary care has plummeted. Between 1990 and 2007, the percentage of internal medicine residents becoming generalists dropped by 80%.
Then there’s office visit duration. Lower reimbursements and changing health status dynamics have translated to significantly shorter visits with more complex patients. Complicated patients who warrant thorough work-ups will often require more time than is allocated, meaning that they may cost more than they generate. This at least partly explains why specialty referrals have doubled in the last decade. Traditional primary care patients have increasingly become specialty cases, exposed to excessive specialty visits, diagnostics and procedures.
The growing inability of primary care physicians to succeed in private practice has precipitated a wholesale flight to health systems, where many doctors become “feeders” for outpatient and inpatient services. In 2010 the Medical Group Management Association reported that the share of practices owned by physicians had dropped from two-thirds to half in only three years. That trend continues.
Many of these dynamics are rooted in the relationship between the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association’s specialist-dominated Relative Value Scale Update Committee (RUC), which formulates recommendations for the value of medical services. This controversial and opaque process – former CMS Administrator Tom Scully recently described it as “highly politicized” and “not objective” – has overvalued specialty services at primary care’s expense, and inhibited primary care’s ability to hold specialty care accountable. Still, despite the RUC’s ongoingdisregard for primary care’s interests and value, primary care societies continue to argue that “being at the table” means having a say.
The need for a new organization
Primary care’s second rate status in the US results from organizational structures that are not constituted to cope with American health policy’s power dynamics. Generalists stand no chance against a far larger, wealthier and more influential health care industry that can field billions of dollars to promote ever-increasing health care spending.
At the same time, no single organization represents primary care professionals’ overarching interests. Nor is there one that aggregates their many groups (and their collective influence) to effect policy change that values primary care as medicine’s foundation. Generalists have diluted their modest influence, which derives from about 30 percent of American physicians, by scattering loyalties among six different medical societies. Several of these societies also advocate for sub-specialist interests that, contrary to their protests, may conflict with those of primary care.
Nor does primary care’s policy agenda meaningfully acknowledge that it isn’t only about them. Within health care, primary care’s competitors are the rest of the health care industry, comprising nearly one-fifth of the US economy. But outside the industry, one group, non-health care business, makes up the other four-fifths. Much larger and more influential than health care, non-health care business has suffered significant harm from American health care’s egregious inflation and waste. It should be primary care’s most powerful ally.
A new primary care society could reinvigorate the debate about what kind of health system our children will inherit. It could broaden primary care’s power base by being inclusive, acknowledging non-physician professionals and other groups in service to primary care’s larger missions, unifying it as a specialty, and embracing a 21st century vision of what medicine can be. Support from non-health care businesses and institutions could extend that power base further, re-establishing primary care in policy as the basis of a medical system built around evidence, appropriateness, efficiency, quality, safety and value.
A new primary care organization would not replace existing medical societies. Instead, it would become strong by convening and emphasizing other societies’ most positive attributes, providing a counterweight to the sub-specialists’ perspective. Ironically, the exemplar for this approach is the American Medical Association, which brought together all medical societies in its House of Delegates, then evolved to advocate against primary care and for specialists. This fact is evidenced by its insistence on disproportionate sub-specialist voting representation on the RUC, American health care’s most influential federal financial advisory panel.
Primary care is in decline because it is fragmented, inwardly focused, and structurally incapable of protecting its mission and value in the face of far larger forces. Within the ferocious world of influence, a new society would seek to drive policy that invests in America by investing in primary care’s capabilities.
Success will require primary care to amass much more power, pooling its resources, aligning with other more powerful groups and developing a unified voice under the umbrella of a new society. Only then could primary care’s value be feasibly reestablished within American health care.