fam medicine making the case andrew bazemore
TRANSCRIPT
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Making the Case: Family Medicine for America’s Health
Andrew Bazemore, MD, MPH
Director, Robert Graham Center
Family Medicine Congressional Conference, 2014
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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
AIR POLUTION COMMUNITY OF SOLUTIONMEDICAL TRADE AREA
Cityville
Medical Center
Figure 1. One city’s communities of solution. Political boundaries, shown in solid linesoften bear little relation to a community’s problem-sheds or its medical trade area.
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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
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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
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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
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Evidence supporting need to support PC prior to reform :Expenditures vs Primary Care Score
UNITED STATES
AUSBEL
GERCAN
DKFIN
NTH
SPASWE 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 2worse Primary Care Score better
Per
Cap
ita
Hea
lth
Car
e E
xpen
dit
ure
s 20
00
Adapted with permission from Starfield B. Policy relevant determinants of health: an international perspective. Health Policy 2002;60:201-21.
UnitedStates
AUS
BELGER
CANFIN
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
Hea
lth
care
Ou
tco
mes
R
ank*
NTH/DK
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The State of our Primary Care Workforce: Best of Times?
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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, MDAm Fam Physician. 2013 Apr & Sept:online.
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Or worst of Times?
13
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Needing 52,000 more…
14
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ACA impacts demand differently across states: PC Supply and Uninsurance
15
AL
AK
AZAR
CA
CO
CTDE
FL
GA
HI
ID
IL
IN
IAKS
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
5060
7080
9010
0P
C/P
opul
atio
n (
1000
00)
5 10 15 20 25Percent Uninsured
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Rapid NP/PA Growth
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Comprehensiveness?:Trends in the Reported Care of Children by FPs
17
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The Health of the Training Pipeline & Primary Care
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Growing: An era of Allopathic, Osteopathic, (and offshore) expansion
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But what will all this growth yield?
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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 Associated With Medical Students' Career JAMA. 2008;300(10):1154-1164
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.2.3
.4.5
.6(m
ean
) p
rimca
re_
r
1980 1985 1990 1995 2000 2005Medical School Year Of Graduation
Allopathic Osteopathic
Trends in Production of Primary Care, by School Type
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.2.3
.4.5
.6(m
ean
) p
rimca
re_
r
1980 1985 1990 1995 2000 2005Medical School Year Of Graduation
Allopathic Osteopathic
Trends in Production of Primary Care, by School Type
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.2.3
.4.5
.6(m
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1980 1985 1990 1995 2000 2005Medical School Year Of Graduation
Private InternationalPublic
Trends in Production of Primary Care, by School Type
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Few Primary Care, 26% remain in state
Wide variation in outcomes
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Many Primary Care, 54% remain in state
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Such variability should be more transparent (www.medschoolmapper.org)
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And what of Graduate Medical Education?
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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 5000002007 Median Specialty Income
Per
cent
Cha
nge
in N
umbe
r of
PY
-1
Ava
ilabl
e
What Teaching Hospitals Do
Weida, Bazemore, Phillips, Archives Internal Med, 2010
Income change adjusted for inflation
1998-2007
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$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
$400,000
$450,000
An
nu
al In
com
e
Year
Driving force: Specialty to PC Payment Gap
Diagnostic
Orthopedic Surgery
Primary Care
Family Medicine
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$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?
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And again, the outcomes vary widely
Primary Teaching Site Name (ACGME)
# Grads # Spec # PC % PC
138. Duke University Hospital 861 71 77 8.94139. Northwestern Memorial Hospital 722 39 64 8.86140. Baylor University Medical Center 170 16 15 8.82141. Vanderbilt University Medical Center 775 55 67 8.65142. Medical Center of Louisiana at New Orleans375 27 32 8.53143. Cleveland Clinic Foundation 761 55 64 8.41145. Brigham and Women's Hospital 844 40 69 8.18146. Temple University Hospital 429 27 34 7.93147. Thomas Jefferson University Hospital 515 43 37 7.18148. Tulane University Hospital and Clinics 382 31 27 7.07149. University of Chicago Medical Center 523 44 35 6.69150. Massachusetts General Hospital 842 42 55 6.53151. Stanford Hospital and Clinics 623 49 29 4.65152. Johns Hopkins Hospital 848 70 39 4.6153. Barnes-Jewish Hospital 848 50 30 3.54154. Harper-Hutzel Hospital 244 17 5 2.05155. Indiana University Health University Hospital411 27 3 0.73156. NYU Hospitals Center 352 29 2 0.57157. Mayo Clinic (Rochester) 243 30 0 0158. Memorial Sloan-Kettering Cancer Center 169 10 0 0
John Peter Smith, #6, 44% PC; lots of FPs serving Texas
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And should be transparent… Residency Footprinting Tool
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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
An
nu
al In
com
e
Year
Driving force: Specialty to PC Payment Gap
Diagnostic
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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
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Decentralized Training Works
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What trains in Vegas… stays in Vegas?
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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
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Failing to extend and expand on GME gains (PCEP, THC) would
signal little commitment to rehabilitate a failing pipeline
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Our future must be team-based, and integrated with Public, Community and Behavioral Health
• http://www.annfammed.org/content/10/3/250.full
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And we remain the frontline for many Americans
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We need change facilitators, and data systems forward that serve
integration, and primary care
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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’
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1000 people
800 have symptoms
327 consider seeking medical care
217 physician’s office113 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:
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√ Health Insurance√ Usual Source of Care
√ Health InsuranceNO Usual Source of Care
NO Health Insurance√ Usual Source of Care
NO Health InsuranceNO Usual Source of Care
This Eco
logy, and Acce
ss, are best
served w
ith a Card AND a Home
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And Care of Complex Chronic Disease is mostly taking place in that Home…
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Remembering our roots1978: 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
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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
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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 VoorheesImproving 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 BrodePrimary 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 StoltenbergEvaluating Educational Health Centers
Loyola University Chicago
Roxanne RichardsRhode Island: A Brief State of the State
University of Virginia
Joanne Wilkinson
People Reporting Functional Disability in NHIS: Descriptors, Primary Care Utilization, and ED Utilization
Boston University
Heather Bennett
Social Deprivation Indices, Primary Care, and Health: A Regional Comparison
University of California, San Francisco
Questions?