Lawmakers Need Guidance to Fix U.S. ‘Wealth Care’ Culture

May 28, 2019 03:14 pm Scott Wilson Washington, D.C. – "This is a hard story to tell using data," Andrew Bazemore, M.D., M.P.H., said May 20 in the first session of the 2019 Family Medicine Advocacy Summit, a talk titled "Making the Case for Primary Care."

But the stitching machinery -- physicians, yes, but also the workforce pipeline, insurance and pharmaceutical companies, hospitals, government -- adds up to something else. "Wealth care," Bazemore called it, providing a sharp shorthand for what FMAS attendees had assembled to push back against.

Understanding the complexity and impact of that apparatus, then conveying where the AAFP's legislative agenda fits within it, would be their mission. They would need research, numbers and trends in hand -- data to undergird individual anecdotes.

"Functionally, medicine is nothing but a social science," he said. "Politics is nothing but medicine on a larger scale. Family medicine leads the way in pointing out the social determinants of health. This is the white hat you walk in wearing when you tell our story. You're here to craft that message."

In a flurry of slides emphasizing findings and publications from the Robert Graham Center, Bazemore composed a data-driven narrative of primary care as both essential frontline medicine and vital social safety net. And it's a narrative that can be redrawn during any legislative visit.

Story Highlights

Location, Location, Location

"We need more training in place," Bazemore said. "If you don't train people in the places they need to serve, you don't get them there."

One way to achieve this aim remains clear, Bazemore told the audience: Push lawmakers to pass the Training the Next Generation of Primary Care Doctors Act, which would reauthorize the Teaching Health Center Graduate Medical Education program for five years. The bill would support community-based primary care and the placement of physicians in rural and underserved areas, he said, ending years of uncertainty and fulfilling a key Academy goal.

Bazemore pointed to an RGC study in which a national census of third-year family medicine residents indicated that those who trained in teaching health centers were more likely to plan to work in safety-net clinics than those who did not train in these centers.

"Building 'primary careness' is one of the challenges of medical value," Bazemore said. "Paying for more training in place-based primary care is part of how you find the value.

"The good news is, we've spent 20 years empirically laying out what we think we should get for our investment in health care in the United States. In a word, it's health. And you can boil it down to the triple aim: better health for your population, better experience for your patients, lower per-capita cost on spending."

Primary Careness and Wealth Care

With discussion of universal health care growing in the runup to the 2020 election, Bazemore acknowledged that comparison of care in the United States to that of other nations would be inevitable. His advice on how to deal with that apples-to-oranges notion in legislative encounters was blunt.

"The most dangerous thing you can do is say, 'Well, what they do in Great Britain …,'" he told the audience.

Instead, he advised looking closer to home, then zeroing in further. "Talk about what is needed in an area, not just for a country, and talk about creating positions there," he said.

"No matter what country you compare us to, we are clearly not delivering value for our investment," he added. "Rank peer countries' primary careness, and you see that we're an outlier. Our outcomes are far on the wrong side."

Data again point to a remedy, however: investment in primary care.

"Primary care is the only true path to universal health care," Bazemore said. "But right now, we are spending 18.3% of our gross domestic product on health care, and that's accelerating.

"What better for a wealthy nation to invest in than its health? The problem is, we aren't investing in health. We're investing in health care."

Bazemore acknowledged the difficulty in convincing a lawmaker to focus on rural health care or teaching health centers rather than trying to land a $100 million health center for a district.

"Call it what it is," he said, "Say to him, 'You are under pressure to create jobs and revenue, but those construction workers are also patients. If you can't figure out how to deliver health, deliver the real value proposition of health to your constituents, it's all for naught.'"

Here, Bazemore drew the audience's attention to a February RGC study on the effect of the primary care workforce on life expectancy.

"It's really important," he said. "Looking at 2005 to 2015, a 10-year window of the primary care supply, it says that when you add 10 family physicians per 100,000 people, you're going to add 51.5 days of mortality benefit (to the population). Adding 10 more specialists per 100,000, you subtract about 20 days" from that increased figure.

The audience chuckled in mordant recognition, and Bazemore politely chided, "It's not really funny."

He went on: "You can walk into your conversations tomorrow and boil down the research to show a real effect on life expectancy. Training in place gets more folks into the primary-care safety net, which is what we want. This is the logical foundation of an effective health care system."

He advised members to supplement reference to that study with mention of the Academy's EveryONE Project.

"You have to remind legislators of all types that patients with high-cost chronic conditions rely heavily on primary care physicians," Bazemore said. "When we go through national data sets on these complex cases, we find the vast majority of touches are with primary care."

Q&A

Bazemore concluded by answering questions from the audience.

"Nurse practitioners will tell lawmakers that they are the answer to primary-care shortage," one family physician said. "Are there studies that prove bad outcomes?"

"There's very little in the way of apples-to-apples comparison between nurse practitioners operating independent practices compared to primary care physicians, but a whole host of badly done studies show equivalency between nurse practitioners and family medicine," Bazemore said.

"I strongly encourage ongoing conversations with legislators about how well we work together in team practice."

Another FP said, "Often the legislators aren't the ones changing the system, compared to health insurers. Why aren't insurers as aggressive in working toward value?"

"I think they are," Bazemore answered. "That capita-to-GDP spend is going up and up and up, and we experience the consequences. We are in the decade when I think it's going to change. Your task is to speak about teaching health centers -- it's critical that you show information that says this program is working, that it's getting more folks into the primary-care safety net, which is what we want."

As time ran out on the session, an audience member asked a final question: "The average primary care physician produces value -- more so than others. But what are we going to do about it?"

"I'll turn it back to you," Bazemore answered. "What are you going to do about it?"

Related AAFP News Coverage
Family Medicine Advocacy Summit 2019
Academy Lauds Lawmakers as Champions of Family Medicine
(5/22/2019)