Editorials

Why Does a U.S. Primary Care Physician Workforce Crisis Matter?

ROBERT L. PHILLIPS, JR., M.D., M.S.P.H.
Robert Graham Center: Policy Studies in Family Practice and Primary Care
Washington, D.C.

BARBARA STARFIELD, M.D., M.P.H.
Johns Hopkins University Bloomberg School of Public Health
Baltimore, Maryland

See Graham Center One-Pagers on pages 1483, 1484, and 1486.

In this issue of American Family Physician , the series of One-Pagers ^1-3 from the Robert Graham Center offer evidence that a primary care workforce crisis may once again be taking shape. The 1990s saw alignment of public policy and funding efforts to increase the primary care workforce, and indeed family medicine training capacity grew by 34 percent. ⁴ U.S. medical students responded, and the primary care physician workforce increased, but the growth of the subspecialist workforce still outstripped that of primary care physicians. Since 1997, U.S. medical school graduate matches in family medicine and general internal medicine programs have fallen by nearly 50 percent. Despite the disproportionate growth of subspecialties, U.S. primary care physicians still provide most of the care to most patients for most conditions most of the time.

*--Rank is based on patient satisfaction, expenditures per person, 14 health indicators, and medications per person. FIGURE 1. Primary care versus outcome indicators (rank 1 is best, rank 12 is worst).

Recent efforts to frame physician workforce policies focus on demand-based models (as opposed to need-based models) and suggest that as Americans' affluence rises, there will be a hue and cry for more subspecialty services. These proposals also suggest that primary care functions will be in less demand and that providers other than physicians will assume these functions. ^4-6 It is important to recognize that what the market will bear may not be what the population can bear when it comes to health care. The U.S. health system's failure to adopt a primary care focus results in poorer health outcomes for all Americans compared with our nation's industrialized peers, and at a much greater cost. Starfield and colleagues have compared the United States with other developed countries and found that the United States ranked lowest in its primary care functions and lowest in health care outcomes, but highest in health care spending (Figures 1 and 2). ^7-10

FIGURE 2. Health care expenditures versus primary care score.

More than two decades of accumulated evidence reveals that having a primary care- based health system matters. People and countries with adequate access to primary care realize a number of health and economic benefits, including the following:

Evidence of Effectiveness

• Reduced all-cause mortality and mortality caused by cardiovascular and pulmonary diseases ¹¹
• Less use of emergency departments and hospitals ^12,13
• Better preventive care ^14,15
• Better detection of breast cancer, and reduced incidence and mortality caused by colon and cervical cancer ^16-18

Evidence of Efficiency

• Fewer tests, higher patient satisfaction, less medication use, and lower care-related costs ^19,20

Evidence of Equity

• Reduced health disparities, particularly for areas with the highest income inequality, including improved vision, more complete immunization, better blood pressure control, and better oral health ^21-23

The United States leads the world in many ways: militarily, economically, and in health care spending. Health care spending of $1.7 trillion per year should be sufficient to place the United States in the lead in health and health care outcomes. However, we find ourselves behind nearly all of our nation's industrialized peers with regard to health outcomes. We face another primary care workforce crisis that is compounded by increased diversion of medical school graduates into subspecialties. We appear to lack the political will to reorient our system to primary care and to provide coverage and access to health care for all Americans.

The policy options for reorienting our health care system to primary care have been on the table for more than a decade ²⁴ and include the following:

• Reimbursement that facilitates and rewards continuous, patient-centered, comprehensive, compassionate, and coordinated care; reimbursement that reflects the special challenges of primary care, fostering patient-focused continuity and maximizing quality and safety; and reimbursement that promotes team practice and offers patients the expertise and training of each member rather than having them compete to fill the same roles
• Developing and supporting information systems and decision-support tools that help primary care physicians and their patients improve the quality of primary health care and to know when it is time to involve subspecialists
• Using state licensing laws, population health needs assessments, and funding to shape an appropriate workforce
• Explicit subsidies for training programs that produce primary care physicians
• Expansion of loan forgiveness for primary care physicians
• Adequate support for practice-based research and primary care health services research
• Measuring and rewarding effective care, especially preventive care services
• Supporting better connections between primary health care, public health, mental health, and subspecialty services

Failure to find the will to change is a path to increasingly poor outcomes, escalating costs, and the dismantling of primary care infrastructures that will take decades to rebuild. There appears to be some resurgence of optimism, or at least urgency, for offering health care coverage for everyone in the United States. ^25,26 If this latest effort develops momentum among the public and policy makers, it may offer an opportunity to develop a health care system that is more appropriately oriented to primary care, and that supports the needed workforce to deliver its promise. Family physicians must become engaged in working through their own organizations, collaborating with other professional primary care organizations, and working with consumer groups to educate the public and policy makers about the need for immediate action.

REFERENCES

1. Biola H, Green LA, Phillips RL, Guirguis-Blake J, Fryer GE. The U.S. primary care physician workforce: minimal growth 1980-1999. Am Fam Physician 2003;68:1483.
2. Biola H, Green LA, Phillips RL, Guirguis-Blake J, Fryer GE. The U.S. primary care physician workforce: persistently declining interest in primary care medical specialties. Am Fam Physician 2003;68: 1484.
3. Biola H, Green LA, Phillips RL, Guirguis-Blake J, Fryer GE. The U.S. primary care physician workforce: undervalued service. Am Fam Physician 2003; 68:1486.
4. Phillips RL, Green LA, Fryer GE, Dovey SM. Uncoordinated growth of the primary care work force. Am Fam Physician 2001;64:1498.
5. Cooper RA, Getzen TE. The coming physician shortage. Health Aff 2002;21:296-9.
6. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff 2002; 21:140-54.
7. Starfield B. Primary care: concept, evaluation, and policy. New York: Oxford University Press, 1992: 6,213-35.
8. Starfield B. Primary care and health. A cross-national comparison. JAMA 1991;266:2268-71.
9. Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002;60:201-18.
10. Starfield B. Is primary care essential? Lancet 1994; 344:1129-33.
11. Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res 2003;38:831-65.
12. Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K, Luri N, et al. Preventable hospitalizations and access to health care. JAMA 1995; 274:305-11.
13. Wasson JH, Sauvigne AE, Mogielnicki RP, Frey WG, Sox CH, Gaudette C, et al. Continuity of outpatient medical care in elderly men. A randomized trial. JAMA 1984;252:2413-7.
14. Bindman AB, Grumbach K, Osmond D, Vranizan K, Stewart AL. Primary care and receipt of preventive services. J Gen Intern Med 1996;11:269-76.
15. Dietrich AJ, Goldberg H. Preventive content of adult primary care: do generalists and subspecialists differ? Am J Public Health 1984;74:223-7.
16. Ferrante JM, Gonzales EC, Pal N, Roetzheim RG. Effects of physician supply on early detection of breast cancer. J Am Board Fam Pract 2000;13:408-14.
17. Campbell RJ, Ramirez AM, Perez K, Roetzheim RG. Cervical cancer rates and the supply of primary care physicians in Florida. Fam Med 2003;35:60-4.
18. Roetzheim RG, Gonzalez EC, Ramirez A, Campbell R, van Durme DJ. Primary care physician supply and colorectal cancer. J Fam Pract 2001;50:1027-31.
19. Greenfield S, Nelson EC, Zubkoff M, Manning W, Rogers W, Kravits RL, et al. Variations in resource utilization among medical specialties and systems of care. Results from the medical outcomes study. JAMA 1992;267:1624-30.
20. Forrest CB, Starfield B. The effect of first-contact care with primary care clinicians on ambulatory health care expenditures. J Fam Pract 1996;43:40-8.
21. Shi L, Starfield B, Politzer R, Regan J. Primary care, self-rated health, and reductions in social disparities in health. Health Serv Res 2002;37:529-50.
22. Lohr KN, Brook RH, Kamberg CJ, Goldberg GA, Leibowitz A, Keesey J, et al. Use of medical care in the Rand Health Insurance Experiment. Diagnosis- and service-specific analyses in a randomized controlled trial. Med Care 1986;24(suppl 9):S1-87.
23. Shi L, Starfield B. The effect of primary care physician supply and income inequality on mortality among blacks and whites in U.S. metropolitan areas. Am J Public Health 2001;91:1246-50.
24. Starfield B, Simpson L. Primary care as part of U.S. health services reform. JAMA 1993;269:3136-9.
25. Woolhandler S, Himmelstein DU, Angell M, Young QD. Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA 2003;290:798-805.
26. Hadley J, Holahan J. Covering the uninsured: how much would it cost? Retrieved September 5, 2003, from: www.healthaffairs.org/WebExclusives/2204Hadley.pdf.

Strategies to Improve Diabetes Care

THOMAS BODENHEIMER, M.D.
University of California, San Francisco, School of Medicine
San Francisco, California

Family physicians might react to a new article about diabetes--such as the one by Gavin and colleagues ¹ in this issue of American Family Physician --by thinking, "Another diabetes article? I know how to care for diabetes. I'll skip this one." Please don't skip this article. Diabetes care is not only about knowledge. If it were, it would be hard to explain why 74 percent of persons with diabetes have uncontrolled blood pressure, 71 percent have elevated lipid levels, and 54 percent have hemoglobin A _1c levels greater than 7 percent. ²

Who is responsible for the inadequacy of diabetes management? Should physicians be blamed? Should patients? Indeed, some physicians are unaware of accepted diabetes guidelines, and patients may be resistant to changing their behavior. However, the main difficulty lies not with physicians or patients but with the health care system. Acute complaints crowd out chronic care management; the painful knee takes priority while less urgent diabetes care gets short shrift (the "tyranny of the urgent"). ³

Physicians' attempts to help patients change their behavior often are not performed productively. ⁴ At times, in the pressured atmosphere of primary care, routine tasks such as ordering blood tests are neglected instead of being delegated to nonphysician personnel who may have more time. Clinical information systems are rarely available, and many physicians are unable to produce a list of their patients with diabetes.

The Chronic Care Model was developed to improve the management of chronic illness. ^5,6 Achieving the goals discussed by Gavin and colleagues ¹ will require primary care practices throughout the country to implement this model. Some of its components include clinical information systems (e.g., registries, reminders, physician feedback), practice redesign (e.g., team care, planned visits, case management), decision support (e.g., practice guidelines, physician education), and self-management support (e.g., patient education, training patients in goal-setting skills). In diabetes management, the most important components may be the registry, reminders, planned visits, physician feedback, and self-management training. ⁶

The foundation of the Chronic Care Model is the registry, which lists all of the patients on a physician's panel who have a chronic condition. A diabetes registry can be derived from practice-management software, pulling the ICD-9 codes of all patients with diabetes. In the ideal situation, data about A _1c levels and low-density lipoprotein (LDL) cholesterol levels can be put into the registry electronically, and blood pressure data can be loaded into the registry from an electronic medical record. However, because most family physicians do not have those capabilities, a medical assistant or billing clerk can input the clinical data (A _1c level, LDL cholesterol level, and blood pressure) from a diabetes flow sheet. Ideally, the registry also would track when the last eye examination and microalbumin test were performed. The registry can be used to generate reminders, provide physician feedback, and classify patients with well-controlled diabetes or poorly controlled diabetes.

Before each patient visit, a medical assistant can print a reminder prompt from the registry and (using a physician-written protocol) order laboratory tests or eye examinations that are overdue, saving the physician time and ensuring that these routine tasks are performed. Reminders are known to be effective; 22 of 26 studies on physician reminders showed improvement in physician performance. ⁷

Registries also can be used to generate letters to patients who are overdue for office follow-up, laboratory tests, or eye examinations. A controlled study of registries with letters to patients found greater reductions in A _1c and LDL cholesterol levels in patients who received letters than in control patients. ⁸

The registry can be used to measure over time the percentage of patients with diabetes who have A _1c levels over 8 percent, LDL cholesterol levels over 130 mg per dL (3.4 mmol per L), and blood pressure levels greater than 130/80 mm Hg. A Cochrane review ⁹ has shown that this kind of physician feedback improves practice, although the effect is less than that achieved by physician reminders.

Patients in the registry can be stratified by A _1c , LDL cholesterol, and blood pressure levels, and patients with poor control can be targeted for planned diabetes visits. These visits, which circumvent the "tyranny of the urgent," have been shown in randomized trials to reduce A _1c levels compared with control subjects. ^10-12 Ideally, the visits are conducted by nurses using physician-generated protocols and combine patient education with medication management.

Finally, patient self-management training is critical to successful care of diabetes and associated hyperlipidemia and hypertension. A comprehensive review of traditional patient education found that patient knowledge increased, but glycemic control did not. ¹³ In one randomized trial, ¹⁴ training in goal setting and problem solving were added to traditional patient education, resulting in improved A _1c levels in the intervention group. Rather than telling patients how to live their lives, it is more productive for physicians to work collaboratively with patients, eliciting their readiness to make behavior changes and agreeing on focused behavior-change action plans. ¹⁵

Address correspondence to Thomas Bodenheimer, M.D., Department of Family and Community Medicine, University of California, San Francisco, Building 80-83, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110 (e-mail: tbodenheimer@medsch.ucsf.edu) Reprints are not available from the author.

REFERENCES

1. Gavin JR 3d, Peterson K, Warren-Boulton E. Reducing cardiovascular disease risk in patients with type 2 diabetes: a message from the National Diabetes Education Program. Am Fam Physician 2003;68:1569-74.
2. Clark CM, Fradkin JE, Hiss RG, Lorenz RA, Vinicor F, Warren-Boulton E. Promoting early diagnosis and treatment of type 2 diabetes: the National Diabetes Education Program. JAMA 2000;284:363-5.
3. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511-44.
4. Anderson RM, Funnell MM. Compliance and adherence are dysfunctional concepts in diabetes care. Diabetes Educ 2000;26:597-604.
5. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-9.
6. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA 2002; 288:1909-14.
7. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-5.
8. Stroebel RJ, Scheitel SM, Fitz JS, Herman RA, Naessens JM, Scott CG, et al. A randomized trial of three diabetes registry implementation strategies in a community internal medicine practice. Jt Comm J Qual Improv 2002;28:441-50.
9. Jamtvedt G, Young J, Kristoffersen D, Thomson OM, Oxman A. Audit and feedback: effects of professional practice and health care outcomes. Cochrane Database Syst Rev 2003:CD000259.
10. Sadur CN, Moline N, Costa M, Michalik D, Mendlowitz D, Roller S, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care 1999;22:2011-7.
11. Wagner EH, Grothaus LC, Sandhu N, Galvin MS, McGregor M, Artz K, et al. Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Diabetes Care 2001;24:695-700.
12. Griffin S, Kinmonth AL. Systems for routine surveillance for people with diabetes mellitus. Cochrane Database Syst Rev 2003:CD000541.
13. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 2001;24:561-87.
14. Anderson RM, Funnell MM, Butler PM, Arnold MS, Fitzgerald JT, Feste CC. Patient empowerment. Results of a randomized controlled trial. Diabetes Care 1995:18:943-9.
15. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002;288:2469-75.