When the World Health Organization assessed health care systems around the globe in 2000, the United States ranked first in expenditures. The nation's health care system, however, ranked 37th in performance, trailing Costa Rica.
Former AAFP President Ted Epperly, M.D., speaks during the National Conference of Family Medicine Residents and Medical Students about flaws in the U.S. health care system and how family medicine can be part of the solution.
"I'm not trying to bust on Costa Rica, it's a great little country," former AAFP President Ted Epperly, M.D., said Aug. 1 during the opening session of the National Conference of Family Medicine Residents and Medical Students here. "But what is wrong with the United States for having this disconnect?"
A strong primary care foundation, Epperly said, is the key to fixing the country's broken health care system.
The United State spends $2.8 trillion a year on health care, or roughly $8,500 per person, he said. That annual total is estimated to reach $4.6 trillion by 2020.
- Former AAFP President Ted Epperly, M.D., said during a speech at the National Conference of Family Medicine Residents and Medical Students that primary care is key to fixing the broken U.S. health care system.
- According to Epperly, increasing the number of primary care physicians in a community improves quality and decreases costs.
- In countries that emphasize prevention, the ratio of subspecialty physicians to primary care physicians is close to 50:50, but in the United States, the mix is closer to 70:30.
"It's a staggering amount of money," said Epperly, who also pointed out that the United States spends two to four times more per capita on health care than most European countries. Furthermore, health care is the leading cause of personal bankruptcy in the country.
Health care represents 16 percent of the nation's gross domestic product, and that figure is expected to reach 25 percent by 2025. Epperly likened the country's escalating spending on the treatment of chronic diseases -- while not properly emphasizing preventive care -- to a community that buys state-of-the art firetrucks, hoses and other equipment for its firehouses but makes no effort to prevent fires in the first place.
"We have the world's best fire department," he said.
Epperly, who is CEO and program director of the Family Medicine Residency of Boise, Idaho, said that the primary goal of a health care system should be to promote wellness and prevent illness, but that's not the system the United States now has.
"We have the wrong focus," he said. "We're not focused on health care at all. We're focused on disease and doing things to people when they have a disease."
In countries that do emphasize prevention, said Epperly, the ratio of subspecialty physicians to primary care physicians is close to 50:50. In the United States, the mix is closer to 70:30.
"We have the wrong team on the field," he said. "We're overpopulated with subspecialists."
A strong primary care system that includes the patient-centered medical home is critical to improving health care, Epperly stressed. Citing Medicare data, he said that as the number of primary care physicians in a community increases, costs go down and quality improves. Conversely, as the number of subspecialists increases, costs increase and quality declines.
Subspecialists tend to "over-order, overdiagnose and overtreat" illness, said Epperly, thereby driving up costs. Meanwhile, family medicine has been undervalued despite its ability to provide a broad scope of services, including maternity care, care for children, end-of-life care, prevention and more.
"We have the skills to meet the needs of patients," he said.
Epperly said that as long as the U.S. health care system pays physicians well for imaging, surgery and procedures while not properly reimbursing physicians for preventive services and care coordination, the workforce will continue to be unbalanced.
In addition to inadequate numbers of primary care physicians, access to care is hindered by inadequate insurance coverage. Epperly said roughly 50 million Americans -- a figure larger than the populations of some European nations -- are uninsured. The upshot is that patients don't see the right physician at the right time, leading to unnecessary use of urgent care and emergency services and a correlating increase in costs to the system.
Having a usual source of care and some type of coverage improves care, said Epperly, and the Patient Protection and Affordable Care Act has the potential to address both issues because it extends coverage to about 20 million more people while also addressing workforce issues.
"This moves health care in the right direction," he said of the Affordable Care Act, which also includes provisions that address cost reforms, insurance reforms, quality and wellness.
What's the real take-home message, according to Epperly? "We can't afford the system we have now."
And although the law's detractors point out that the Affordable Care Act leaves much to be desired, "When patients start to understand what (health care reform) means for their health, that will get us over the hump," Epperly said. Otherwise, he added, "the next thing will be single payer."