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Tuesday Sep 17, 2019

Invest in FPs and Maybe Insurance Won't Cost as Much as a Car

"You are an obsession. You're my obsession. Who do you want me to be?"
-- Animotion

[stethoscope and money]

I would like to lead off with a Captain Obvious-type statement: The costs of health care services are increasing at an alarming rate.

According to the Kaiser Family Foundation,(www.healthsystemtracker.org) the average cost of an employer-sponsored insurance policy for a family of four now exceeds $22,000 per year. As Axios points out,(www.axios.com) that absurd amount is roughly the same as the price of a new car. Although a majority of this cost is covered by employers, individual contributions in the form of premiums and out-of-pocket costs now exceed, on average, $7,500. During the past 10 years, out-of-pocket costs have increased 58%, or more than twice as much as wages (26%).

The economic strain caused by rising health care costs is not limited to individuals and families; they are negatively impacting businesses and the long-term budget outlooks of government health programs, as well. Everyone is familiar with the "Medicare is going insolvent" declarations(www.nytimes.com) that appear each April when the Medicare trustees report(www.cms.gov) is published. (As an aside, the 2004 report(www.cbsnews.com) predicted Medicare would go broke in 2019. It was close, but it appears that Medicare is still humming along.)

The rapid growth in cost of health care services and spending calls for the identification and implementation of policies that will reduce per capita and overall spending, while not limiting access or decreasing quality -- no small feat. It is well established that an important contributor to accomplishing these goals is making primary care foundational to our health care system and ensuring that every American has a longitudinal relationship with a primary care physician. Few interventions have been proven to increase access, improve quality and reduce per capita spending, but primary care is one of them. The late Barbara Starfield, M.D., M.P.H., and others have demonstrated this through their research.

I strongly support and promote the value of first contact, comprehensive, continuous and coordinated primary care to individuals and our health care system, and I wrote recently about misplaced priorities and the consequences of underinvesting in primary care. The large body of literature that illustrates and defends the overall value of primary care and family medicine to health, wellness, prevention and positive health outcomes -- along with data that show an association between longitudinal primary care and lower per capita spending -- are compelling. Policymakers at all levels should accelerate overall investments in primary care, including increasing compensation for primary care physicians.

Despite all this evidence, there is still something missing from our current debate that bothers me. It is complicated to articulate, so bear with me.

With costs becoming a more prominent factor in the financial decisions of individuals, families, companies and governments, I have become acutely focused on, maybe even obsessed with, not simply proving the value of family medicine to health and wellness, but also demonstrating the significant return on investment family medicine yields. In my opinion, we need to formulate and articulate an economic argument that promotes the fact that every dollar invested in family medicine has a profoundly more positive impact on individuals, communities and our health care system than any dollar invested in other disciplines.

A full-scope family physician is trained to provide care to adults of all ages, children and adolescents. All family physicians are trained in and capable of providing obstetrical services, mental and behavioral care, inpatient/hospital care and emergency care. They also are able to work in nursing homes, hospice, lifestyle and sports medicine, travel medicine, physical and rehabilitation medicine, etc. You get my point.

Family medicine is without peer when it comes to comprehensiveness. As a matter of workforce policy -- and this is important -- family physicians can provide a broader scope of services to each individual patient, thus reducing current levels of necessary workforce for some nonsurgical specialists.

When you explore the potential of artificial intelligence and machine learning to drive an expansion of comprehensiveness in family medicine, its scope grows even broader. The concept of democratization and distribution of information at the point of care would allow family physicians to provide care to a larger number of patients with more complex medical conditions who traditionally have been diagnosed and managed by a subspecialist.

I took this argument to my friend and colleague Andrew Bazemore, M.D., the former director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. As is often the case when I seek Andrew's counsel, he immediately zeroed in on the point: "The plasticity of family medicine is greater than that of other disciplines of medicine," he said.

"Yes, exactly!" I thought. "Wait, what is 'plasticity'?"

Plasticity(www.merriam-webster.com) is the quality of being easily shaped or molded. The concept of plasticity in family medicine originated with Erin Fraher, Ph.D., M.P.P.,(www.med.unc.edu) a professor and researcher at the University of North Carolina at Chapel Hill School of Medicine.

Andrew pointed me in an interesting direction, which is this: The plasticity of family medicine allows the discipline to maximize its capabilities in response to the needs of the patient and/or community being served. Here is his assessment: "Family physicians are the most dynamic, adaptable components of the health workforce, capable of meeting any local need or challenge in any environment where they choose to serve."

Based on this, I have zeroed in on a working hypothesis: The most prudent place to invest any single health care dollar is in family medicine. Not primary care in general, but family medicine specifically.

Now, when I look at annual physician salary reports, I am always struck by the fact that the disciplines at the top end of the income scale have extremely limited scopes of work. Irrespective of the complexity of their core services, the comprehensiveness of their services is narrow.

When you look toward the bottom of the income scale, you tend to find that the scope of work is more comprehensive. The relationship between plasticity and compensation is almost completely inverse. The narrower the scope of services within the discipline, the higher the average salary and vice versa. Clearly, this is wrong and represents a poor distribution of resources. Why, oh why, are we investing so many resources in people who provide limited services to a homogenous cohort of patients and investing so little in those who provide a broad scope of services to a diverse cohort of people?

I obviously want family physicians to be well compensated for the services you provide, and the AAFP is actively working to increase both the overall investment in primary care and compensation rates for family physicians. However, I also want a health care system that invests its resources in the most appropriate manner, and currently, we are not doing this.

As costs of health care services continue to rise, and patients, businesses and governments face increasing costs, I see this developing economic argument of ROI per health care dollar being discussed more often, and the AAFP will be front and center arguing that investing in comprehensive family medicine is the best choice for patients and our health care system.

This was a rough explanation of my thinking, and I apologize that it reads like a ride on a rollercoaster. I promise I will fine-tune this argument, but in the meantime, I welcome your thoughts on this hypothesis and argument.

I hope to see many of you next week at the Family Medicine Experience in Philadelphia. Please stop me to say hello and share your thoughts and suggestions on what the AAFP could be/should be doing to support you in your practice. I always welcome these conversations.  

Posted at 06:21AM Sep 17, 2019 by Shawn Martin

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Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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