1. Making the Case: Family Medicine for
America’s Health
Andrew Bazemore, MD, MPH
Director, Robert Graham Center
Family Medicine Congressional Conference, 2014
2.
3.
4.
5. Definers of Primary Care, Family
Medicine, and its essential role
• 1920s: Dawson Report, U.K.
• 1960s: Millis, Willard, Folsom Reports – US
• 1970s: Lalonde Report, Canada
Centerville
WATER CONTROL COMMUNITY OF SOLUTION
COUNTY LINE
STATE LINE
AIR POLUTION COMMUNITY OF SOLUTION
MEDICAL TRADE AREA
Cityville
Medical Center
TOWN LINE
Figure 1. One city’s communities of solution. Political boundaries, shown in solid lines
often bear little relation to a community’s problem-sheds or its medical trade area.
6. 1978: Declaration of Alma Ata
“Primary care is essential health care based on
practical, scientifically sound and socially acceptable
methods and technology made universally accessible
to individual and families in the community through
their full participation and at a cost that the community
and country can afford…
It forms an integral part of both the country‟s health
system, of which it is the central function and main
focus, and overall social economic development of the
community
7. Primary care is the provision of integrated, accessible
health care services by clinicians who are accountable
for addressing a large majority of personal health care
needs, developing a sustained partnership with
patients, and practicing in the context of family and
community.
Primary care is the “logical foundation of an effective
health care system,” and, “essential to achieving the
objectives that together constitute value in health care.”
Institute of Medicine, 1996
8. How does health in the US compare?
World Health Organization, 2000 Report
• Country DALE Rank Overall Rank
• France 4 1
• Japan 9 10
• UK 24 18
• Cuba 36 39
• Canada 35 30
• US 72 37
2008 World Health Report:
Primary Care – Now more than Ever
9. Evidence supporting need to support PC prior to reform :
Expenditures vs Primary Care Score
UNITED STATES
AUSBEL
GER
CAN
DKFIN
NTH
SPA
SWE UK
FRA
JAP
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2
worse Primary Care Score better
PerCapitaHealthCare
Expenditures2000
Adapted with permission from Starfield B. Policy relevant determinants of
health: an international perspective. Health Policy 2002;60:201-21.
United
States
AUS
BEL
GER
CAN
FIN
SP
SWE
UK
0
1
2
3
4
5
6
7
8
9
10
0 1 2 3 4 5 6 7 8 9 10 11 12
better------Primary care score ranking-------worse
HealthcareOutcomes
Rank*
NTH/DK
10. The State of our Primary Care
Workforce: Best of Times?
11. Historical perspective suggests longterm
boom: Phys/Pop Ratios 1980-2010
LAURA A. MAKAROFF, DO; LARRY A. GREEN, MD; STEPHEN M. PETTERSON, PhD; and ANDREW W. BAZEMORE, MD
Am Fam Physician. 2013 Apr & Sept:online.
14. ACA impacts demand differently across
states: PC Supply and Uninsurance
15
AL
AK
AZAR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
5060708090
100
5 10 15 20 25
Percent Uninsured
23. Student Interest
• General Internal Medicine 2.0%
• Med/Peds 2.7%
• Family Medicine 4.9%
• General Pediatrics
11.7%
• Total: 21.3%
K. E. Hauer et al. Choices Regarding Internal Medicine Factors Assoc
With Medical Students' Career JAMA. 2008;300(10):1154-1164
24. .2.3.4.5.6
1980 1985 1990 1995 2000 2005
Medical School Year Of Graduation
Allopathic Osteopathic
Trends in Production of Primary Care, by School Type
25. .2.3.4.5.6
1980 1985 1990 1995 2000 2005
Medical School Year Of Graduation
Allopathic Osteopathic
Trends in Production of Primary Care, by School Type
26. .2.3.4.5.6
1980 1985 1990 1995 2000 2005
Medical School Year Of Graduation
Private International
Public
Trends in Production of Primary Care, by School Type
31. M. H. Ebell. Future Salary and US
Residency Fill Rate RevisitedJAMA.
2008;300
GME Follows Green($)
What Teaching Hospitals Do
Anesthesiology (21%)
Dermatology (40%)
Radiology (25%)
Ophthalmology (12%)
Family Medicine (-4%)
Pediatrics (-8%)
General Internal
Medicine (2%)
-30
-20
-10
0
10
20
30
0 100000 200000 300000 400000 500000
2007 Median Specialty Income
PercentChangeinNumberofPY-1
Available
What Teaching Hospitals Do
Weida, Bazemore,
Phillips, Archives
Internal
Med, 2010
Income change
adjusted for inflation
1998-2007
33. $13 billion in public investment for
what? (GME Outcomes Study)
We examined current practice for all 2006-08 grads:
• Avg overall primary care production rate: 25.2%.
• 759 sponsoring institutions, 158 produced 0 PC
graduates, 184 (small) produced more than 80%.
• 4.8% of graduates practiced in rural areas
– 198 institutions produced no rural physicians,
– 283 institutions produced no Federally Qualified Health Center or
Rural Health Clinic physicians.
• Additional studies underway –
– Does training in a high cost area yield high cost physicians?
– What additional institutional factors explain
this variation in training outcomes?
34. And again, the outcomes vary widely
Primary Teaching Site Name
(ACGME)
# Grads # Spec # PC % PC
138. Duke University Hospital 861 71 77 8.94
139. Northwestern Memorial Hospital 722 39 64 8.86
140. Baylor University Medical Center 170 16 15 8.82
141. Vanderbilt University Medical Center 775 55 67 8.65
142. Medical Center of Louisiana at New Orleans375 27 32 8.53
143. Cleveland Clinic Foundation 761 55 64 8.41
145. Brigham and Women's Hospital 844 40 69 8.18
146. Temple University Hospital 429 27 34 7.93
147. Thomas Jefferson University Hospital 515 43 37 7.18
148. Tulane University Hospital and Clinics 382 31 27 7.07
149. University of Chicago Medical Center 523 44 35 6.69
150. Massachusetts General Hospital 842 42 55 6.53
151. Stanford Hospital and Clinics 623 49 29 4.65
152. Johns Hopkins Hospital 848 70 39 4.6
153. Barnes-Jewish Hospital 848 50 30 3.54
154. Harper-Hutzel Hospital 244 17 5 2.05
155. Indiana University Health University Hospital411 27 3 0.73
156. NYU Hospitals Center 352 29 2 0.57
157. Mayo Clinic (Rochester) 243 30 0 0
158. Memorial Sloan-Kettering Cancer Center 169 10 0 0
John Peter
Smith, #6, 44%
PC; lots of FPs
serving Texas
35. And should be transparent… Residency
Footprinting Tool
36. So other than reduce the payment
gap, what can we do?
$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
AnnualIncome
Year
Driving force: Specialty to PC PaymentGap
Diagnostic
37. Redistribution of slots to date has failed
• 2003, Medicare Modernization Act
– Redistributed nearly 3000 GME slots
– Goal: Benefit Primary Care & Rural
– Our findings:
• Only 12 of 300 hospitals recipients of slots are
rural, only 3% of all slots are rural
• Redistributed slots = 2:1 Specialty:Primary Care
40. Rural Training Tracks
• 18 going on 30, small but efficient producers
Our evaluation shows:
• 76% of grads practicing in the 13 states with
RTTs at the time of study
• >50% wkg in Rural (2-3x average for FP
programs; far beyond the 4.8% of all GME
grads working rural in our national study of all
specialties (Acad Med 2013)
• 48% in FQHC/RHC/CAH
• 41% in HPSAs, Yr 1 post grad
41. Failing to extend and expand on GME gains
(PCEP, THC) would signal little commitment
to rehabilitate a failing pipeline
42. Our future must be team-based, and
integrated with Public, Community and
Behavioral Health
• http://www.annfammed.org/content/10/3/250
.full
44. We need change facilitators, and data
systems forward that serve
integration, and primary care
45. And remember…to most Policymakers:
Primary Care remains a Solution
• Starfield (and many others):
– Systems built around primary care have
• Lower costs
• Higher quality
• Broader access
• The ACA endorsed this solution, and widely
expanded the number of Americans with „a card‟
• Remind policymakers where most
care, particularly complex care, is occurring, and
that real access requires „a card and a home‟
46. 1000 people
800 have symptoms
327 consider seeking
medical care
217 physician’s
office
113 primary care
65 CAM provider
21 hospital clinic
14 home health
13 emergency
8 hospital
<1 academic health
center hospitalNew Ecology of Medical Care – 2000, NEJM
In an average month:
47. √ Health Insurance
√ Usual Source of Care
√ Health Insurance
NO Usual Source of
Care
NO Health Insurance
√ Usual Source of Care
NO Health Insurance
NO Usual Source of
Care
48. And Care of Complex Chronic Disease is mostly
taking place in that Home…
49. Remembering our roots
1978: Declaration of Alma Ata
“Primary care is essential health care based on
practical, scientifically sound and socially
acceptable methods and technology made
universally accessible to individual and families
in the community through their full participation
and at a cost that the community and country
can afford…
It forms an integral part of both the country‟s
health system…and overall social economic
development of the community
50. Final Thoughts
• Primary Care is needed, “Now More than
Ever”, and your Advocacy on its behalf is
essential and appreciated
• We exist to support your efforts with
evidence, and more information is readily
available at www.graham-center.org
51. Who We Are: A Family of Primary Care Scholars
• 115 Larry A. Green
Visiting Scholars
• 12 Robert L. Phillips
Policy Fellows
– Dr. Laura
Makaroff, now a
Medical Officer for
HRSA Bureau of
Primary Care
Georga Cooke
"Community
Competence" and
Geography
University of
Queensland
(Australia)
Jennifer Voorhees
Improving Primary
Care Physician
Compensastion
Thomas Jefferson
University
Patricia Stoeck
The Medical Home
and Health Care
Transition Counseling
for Youth with Special
Health Care Needs
Georgetown
University
Erica Brode
Primary Care in the
ACO
University of
California, San
Francisco
Amy Marietta
Primary Care and
Health Care Access in
Western North
Carolina
University of North
Carolina at Chapel
Hill
Mark Stoltenberg
Evaluating
Educational Health
Centers
Loyola University
Chicago
Roxanne Richards
Rhode Island: A Brief
State of the State
University of Virginia
Questions?
Editor's Notes
The Best of times?...
By 2013, you’ll have 3500 more Allopathic students per year than in 2002
Without a national planning body coordinating growth, it remains haphazard at best, subject to the whims of Deans and financiers and resembling more of an arms race between States, Deans, and financial backers than a purposeful or strategic process. This past December, We published the first look at Medical School expansion at a state level, and its relationship with existing Primary Care need and found no discernable statistical correlation. Some states with large ratios of PC/Pop and MD/DO students/pop were expanding, including MIchigan despite its loss of population over the preceding 10 years. Others, like Utah, starting with a low number of PC/pop or students/pop, were not
We’ve also built a tool for North Carolina that uses local data to improve health outcomes in the state. (you know more about this than I do. I picked non-white and stroke deaths as my example- in the side-by side map it’s not surprising –high stroke deaths in areas that are high non-white but then the comparison map allows us to look at high/ low and low/high etc. but you can pick a different example. Im kinda running out of steam here…
And reiterated throughout the 2008 WHO Report – the four key features of primary care (person-centredness, comprehensiveness and integration, continuity of care, and participation of patients, families and communities)