Frank Hope has walked with a limp since contracting polio in the 1940s. When he watches his daughter run after her young toddler, he feels a sense of gratitude that the era of vaccination has protected his child and grandchild from such a disabling infection. He recalls the excitement that gripped the nation as the Salk polio vaccine was first tested and then adopted into widespread use. In Frank’s mind, these types of scientific breakthroughs attest to the wonders of the US health care system.
Frank’s grandson attends a day-care program. Ruby, a 3-year-old girl in the program, was recently hospitalized for a severe asthma attack complicated by pneumococcal pneumonia. She spent 2 weeks in a pediatric intensive care unit, including several days on a respirator. Ruby’s mother works full-time as a bus driver while raising three children. She has comprehensive private health insurance through her job but finds it difficult to keep track of all her children’s immunization schedules and to find a physician’s office that offers convenient appointment times. She takes Ruby to an evening-hours urgent care center when Ruby has some wheezing but never sees the same physician twice. Ruby never received all her pneumococcal vaccinations or consistent prescription of a steroid inhaler to prevent a severe asthma attack. Ruby’s mother blames herself for her child’s hospitalization.
People in the United States rightfully take pride in the technologic accomplishments of their health care system. Innovations in biomedical science have almost eradicated scourges such as polio and measles and have allowed such marvels as organ transplantation, “knifeless” gamma-ray surgery for brain tumors, and intensive care technology that saves the lives of children with asthma complicated by pneumonia. Yet for all its successes, the health care system also has its failures. For example, asthma is the most common cause of hospitalization in childhood (Akinbami et al, 2009). Proper medical care can markedly reduce the frequency of severe asthma symptoms and of asthma hospital admissions. In cases such as Ruby’s, the failure to prevent severe asthma flare-up is not related to financial barriers, but rather reflects organizational problems, particularly in the delivery of primary care and preventive services.
The organizational task facing all health care systems is one of “assuring that the right patient receives the right service at the right time and in the right place” (Rodwin, 1984). An additional criterion could be “… and by the right caregiver.” The fragmented care Ruby received for her asthma is an example of this challenge. Who is responsible for planning and ensuring that every child receives the right service at the right time? Can an urgent care center or an in-store clinic at Wal-Mart designed for episodic needs be held accountable for providing comprehensive care to all patients passing through its doors? Should parents be expected to make appointments for routine visits at medical offices and clinics, or should public health nurses travel to homes and day-care centers to provide preventive services out in the community? What is the proper balance between intensive care units that provide life-saving services to critically ill patients and primary care services geared toward less dramatic medical and preventive needs?
The previous chapters have emphasized financial transactions in the health care system. In this chapter and the following one, the organization of the health care system will be the main focus. While considerable debate has dwelled on how to improve financial access to care, less emphasis has been given to the question “access to what?” In this chapter, organizational systems will be viewed through a wide-angle lens, with emphasis on such broad concepts as the relationship between primary, secondary, and tertiary levels of care, and the influence of the biomedical paradigm and medical professionalism in shaping US health care delivery. In Chapter 6, a zoom lens will be used to focus on specific organizational models that have appeared (often only to disappear) in this country over the past century.
One concept is essential in understanding the topography of any health care system: the organization of care into primary, secondary, and tertiary levels. In the Lord Dawson Report, an influential British study written in 1920, the author (1975) proposed that each of the three levels of care should correspond with certain unique patient needs.
1. Primary care involves common health problems (eg, sore throats, diabetes, arthritis, depression, or hypertension) and preventive measures (eg, vaccinations or mammograms) that account for 80% to 90% of visits to a physician or other caregiver.
2. Secondary care involves problems that require more specialized clinical expertise such as hospital care for a patient with acute renal failure.
3. Tertiary care, which lies at the apex of the organizational pyramid, involves the management of rare and complex disorders such as pituitary tumors and congenital malformations.
Two contrasting approaches can be used to organize a health care system around these levels of care: (1) the carefully structured Dawson model of regionalized health care and (2) a more free-flowing model.
1. One approach uses the Dawson model as a scaffold for a highly structured system. This model is based on the concept of regionalization: the organization and coordination of all health resources and services within a defined area (Bodenheimer, 1969). In a regionalized system, different types of personnel and facilities are assigned to distinct tiers in the primary, secondary, and tertiary levels, and the flow of patients across levels occurs in an orderly, regulated fashion. This model emphasizes the primary care base.
2. An alternative model allows for more fluid roles for caregivers, and more free-flowing movement of patients, across all levels of care. This model tends to place a higher value on services at the tertiary care apex than at the primary care base.
Although most health care systems embody elements of both models, some gravitate closer to one polarity or the other. The British National Health Service (NHS) and some large integrated delivery systems in the United States resemble the regionalized approach, while US health care as a whole traditionally followed the more dispersed format.
Basil, a 60-year-old man living in a London suburb, is registered with Dr. Prime, a general practitioner in his neighborhood. Basil goes to Dr. Prime for most of his health problems, including hay fever, back spasms, and hypertension. One day, he experiences numbness and weakness in his face and arm. By the time Dr. Prime examines him later that day, the symptoms have resolved. Suspecting that Basil has had a transient ischemic attack, Dr. Prime prescribes aspirin and refers him to the neurologist at the local hospital, where a carotid artery sonogram reveals high-grade carotid stenosis. Dr. Prime and the neurologist agree that Basil should make an appointment at a London teaching hospital with a vascular surgeon specializing in head and neck surgery. The surgeon recommends that Basil undergo carotid endarterectomy on an elective basis to prevent a major stroke. Basil returns to Dr. Prime to discuss this recommendation and inquires whether the operation could be performed at a local hospital closer to home. Dr. Prime informs him that only a handful of London hospitals are equipped to perform this type of specialized operation. Basil schedules his operation in London and several months later has an uncomplicated carotid endarterectomy. Following the operation, he returns to Dr. Prime for his ongoing care.
The British NHS has traditionally typified a relatively regimented primary—secondary—tertiary care structure (Figure 5–1).
Figure 5–1. Organization of services under the traditional National Health Service model in the United Kingdom. Care is organized into distinct levels corresponding to specific functions, roles, administrative units, and population bases.
1. For physician services, the primary care level is virtually the exclusive domain of general practitioners (commonly referred to as GPs), who practice in small- to medium-sized groups and whose main responsibility is ambulatory care. Two-thirds of all physicians in the United Kingdom are GPs.
2. The secondary tier of care is occupied by physicians in such specialties as internal medicine, pediatrics, neurology, psychiatry, obstetrics and gynecology, and general surgery. These physicians are located at hospital-based clinics and serve as consultants for outpatient referrals from GPs, in turn routing most patients back to GPs for ongoing care needs. Secondary-level physicians also provide care to hospitalized patients.
3. Tertiary care subspecialists such as cardiac surgeons, immunologists, and pediatric hematologists are located at a few tertiary care medical centers.
Hospital planning follows the same regionalized logic as physician services. District hospitals are local facilities equipped for basic inpatient services. Regional tertiary care medical centers handle highly specialized inpatient care needs.
Planning of physician and hospital resources within the NHS occurs with a population focus. GP groups provide care to a base population of 5000 to 50,000 persons, depending on the number of GPs in the practice. District hospitals have a catchment area population of 50,000 to 500,000, while tertiary care hospitals serve as referral centers for a population of 500,000 to 5 million (Fry, 1980).
Patient flow moves in a stepwise fashion across the different tiers. Except in emergency situations, all patients are first seen by a GP, who may then steer patients toward more specialized levels of care through a formal process of referral. Patients may not directly refer themselves to a specialist.
While nonphysician health professionals, such as nurses, play an integral role in staffing hospitals at the secondary and tertiary care levels, especially noteworthy is the NHS’ multidisciplinary approach to primary care. GPs work in close collaboration with practice nurses (similar to nurse practitioners in the United States), home health visitors, public health nurses, and midwives (who attend most deliveries in the United Kingdom). Such teamwork, along with accountability for a defined population of enrolled patients and universal health care coverage, helps to avert such problems as missed childhood vaccinations. Public health nurses visit all homes in the first weeks after a birth to provide education and assist with scheduling of initial GP appointments. A national vaccination tracking system notifies parents about each scheduled vaccination and alerts GPs and public health nurses if a child has not appeared at the appointed time. As a result, more than 85% of British preschool children receive a full series of immunizations. (The British NHS is discussed at greater length in Chapter 14.)
A number of other nations, ranging from industrialized countries in Scandinavia to developing nations in Latin America, have adopted a similar approach to organizing health services. In developing nations, the primary care tier relies more on community health educators and other types of public health personnel than on physicians.
Polly Seymour, a 55-year-old woman with private health insurance who lives in the United States, sees several different physicians for a variety of problems: a dermatologist for eczema, a gastroenterologist for recurrent heartburn, and an orthopedist for tendinitis in her shoulder. She may ask her gastroenterologist to treat a few general medical problems, such as borderline diabetes. On occasion, she has gone to the nearby hospital emergency department for treatment of urinary tract infections. One day, Polly feels a lump in her breast and consults a gynecologist. She is referred to a surgeon for biopsy, which indicates cancer. After discussing treatment options with Polly, the surgeon performs a lumpectomy and refers her to an oncologist and radiation therapy specialist for further therapy. She receives all these treatments at a local hospital, a short distance from her home.
The US health care system has had a far less structured approach to levels of care than the British NHS. In contrast to the stepwise flow of patient referrals in the United Kingdom, insured patients in the United States, such as Polly Seymour, have traditionally been able to refer themselves and enter the system directly at any level. While many patients in the United Kingdom have a primary care physician (PCP) to initially evaluate all their problems, many people in the United States have become accustomed to taking their symptoms directly to the specialist of their choice.
One unique aspect of the US approach to primary care has been to broaden the role of internists and pediatricians. While general internists and general pediatricians in the United Kingdom and most European nations serve principally as referral physicians in the secondary tier, their US counterparts share in providing primary care. Moreover, the overlapping roles among “generalists” in the United States (GPs, family physicians, general internists, and general pediatricians) are not limited to the outpatient sector. PCPs in the United States have assumed a number of secondary care functions by providing substantial amounts of inpatient care. Only recently has the United States moved toward the European model that removes inpatient care from the domain of PCPs and assigns this work to “hospitalists”—physicians who exclusively practice within the hospital (Wachter and Goldman, 1996).
Including general internists and general pediatricians, the total supply of generalists amounts to approximately one-third of all physicians in the United States, a number well below the 50% or more found in Canada and many European nations (Starfield, 1998). To fill in the primary care gap, some physicians at the tertiary care level in the United States have also acted as PCPs for some of their patients. In contrast to physicians, nurse practitioners and physician assistants are more likely to work in primary care settings and are a key component of the nation’s clinical workforce.
US hospitals are not constrained by rigid secondary and tertiary care boundaries. Instead of a pyramidal system featuring a large number of general community hospitals at the base and a limited number of tertiary care referral centers at the apex, hospitals in the United States each aspire to offer the latest in specialized care. In most urban areas, for example, several hospitals compete with each other to perform open heart surgery, organ transplants, radiation therapy, and high-risk obstetric procedures. The resulting structure resembles a diamond more than a pyramid, with a small number of hospitals (mostly rural) that lack specialized units at the base, a small number of elite university medical centers providing highly superspecialized referral services at the apex, and the bulk of hospitals providing a wide range of secondary and tertiary services in the middle.
Critics of the US health care system find fault with its “top-heavy” specialist and tertiary care orientation and lack of organizational coherence. Analyses of health care in the United States over the past half century abound with such descriptions as “a nonsystem with millions of independent, uncoordinated, separately motivated moving parts,” “fragmentation, chaos, and disarray,” and “uncontrolled growth and pluralism verging on anarchy” (Somers, 1972; Halvorson and Isham, 2003). The high cost of health care has been attributed in part to this organizational disarray. Quality of care may also suffer. For example, when many hospitals each perform small numbers of surgical procedures such as coronary artery bypass grafts, mortality rates are higher than when such procedures are regionalized in a few higher-volume centers (Grumbach et al, 1995).
Defenders of the dispersed model reply that pluralism is a virtue, promoting flexibility and convenience in the availability of facilities and personnel. In this view, the emphasis on specialization and technology is compatible with values and expectations in the United States, with patients placing a high premium on direct access to specialists and tertiary care services, and on autonomy in selecting caregivers of their choice for a particular health care need. Similarly, the desire for the latest in hospital technology available at a convenient distance from home competes with plans to regionalize tertiary care services at a limited number of hospitals.
Dr. Billie Ruben completed her residency training in internal medicine at a major university medical center. Like most of her fellow residents, she went on to pursue subspecialty training, in her case gastroenterology. Dr. Ruben chose this career after caring for a young woman who developed irreversible liver failure following toxic shock syndrome. After a nerve-racking, touch-and-go effort to secure a donor liver, transplantation was performed and the patient made a complete recovery.
Upon completion of her training, Dr. Ruben joined a growing subspecialty practice at Atlantic Heights Hospital, a successful private hospital in the city. Even though the metropolitan area of 2 million people already has two liver transplant units, Atlantic Heights has just opened a third such unit, feeling that its reputation for excellence depends on delivering tertiary care services at the cutting edge of biomedical innovation. In her first 6 months at the hospital, Dr. Ruben participates in the care of only two patients requiring liver transplantation. Most of her patients seek care for chronic, often illdefined abdominal pain and digestive problems. As Dr. Ruben begins seeing these patients on a regular basis, she starts to give preventive care and treat nongastrointestinal problems such as hypertension and diabetes. At times she wishes she had experienced more general medicine during her training.
Advocates of a stronger role for primary care in the United States believe that it is too important to be considered an afterthought in health planning. In this view, overemphasis on the tertiary care apex of the pyramid creates a system in which health care resources are not well matched to the prevalence and incidence of health problems in a community. In an article entitled “The Ecology of Medical Care” published more than four decades ago, Kerr White recorded the monthly prevalence of illness for a general population of 1000 adults (White et al, 1961). In this group, 750 experienced one or more illnesses or injuries during the month. Of these patients, 250 visited a physician at least once during the month, nine were admitted to a hospital, and only one was referred to a university medical center. Dr. White voiced concern that the training of health care professionals at tertiary care–oriented academic medical centers gave trainees like Dr. Billie Ruben an unrepresentative view of the health care needs of the community.
Serious questions can be raised about the nature of the average medical student’s experience, and perhaps that of some of this student’s clinical teachers, with the substantive problems of health and disease in the community. In general, this experience must be both limited and unusually biased if, in a month, only 0.0013 of the “sick” adults. … or 0.004 of the patients . . . . in a community are referred to university medical centers. . . . Medical, nursing, and other students of the health professions cannot fail to receive unrealistic impressions of medicine’s task in contemporary Western society. . . . (White et al, 1961)
Updating Kerr White’s findings, Larry Green found precisely the same patterns four decades later (Green et al, 2001).
An English GP, John Fry (1980) conducted a related study of the ecology of care, in which he systematically recorded the types of health problems that brought patients to his office in the 1970s. Because of the GP’s function as a gatekeeper under the NHS, Dr. Fry’s investigation provides a close approximation of the full incidence and prevalence of diseases requiring medical attention among his population of registered patients (Table 5–1). The dominant pathology in this unselected population consisted of minor ailments (many of which would have improved without treatment), chronic conditions such as hypertension and arthritis, and gradations of mental illness. The incidence of new cancers was relatively rare, and only a handful of patients manifested complex syndromes such as multiple sclerosis. Although the specific pattern of illnesses differs for a US family physician practicing in the 21st century compared with the pattern for a British GP in the 1970s (eg, human immunodeficiency virus infection and Alzheimer disease do not appear in Table 5–1), the general pattern remains true. Dr. Fry’s study confirms the adage that “common disorders commonly occur and rare ones rarely happen.”
Table 5–1. Persons per year seeking care in a general practitioner practice with a registered population of 2500, according to problem
Although these analyses suggest that most health needs can be met at the primary care level, this observation should not imply that most health care resources should be devoted to primary care. The minority of patients with severe or complicated conditions requiring secondary or tertiary care will command a much larger share of health care resources per capita than the majority of people with less dramatic health care needs. Treating a patient with liver failure costs a great deal more than treating a patient for a sore throat. Even in the United Kingdom, where the 65% of physicians who are GPs provide 60% of all ambulatory care, expenditures on their services account for less than 10% of the overall NHS budget, whereas the cost of inpatient and outpatient hospital care at the secondary and tertiary levels consumes nearly two-thirds of the budget. Thus, the pyramidal shape shown in Figure 5–1 better represents the distribution of health care problems in a community than the apportionment of health care expenditures. While almost all industrialized nations devote a dominant share of health care resources to secondary and tertiary care, the ecologic view reminds us that most people have health care needs at the primary care level.
Dr. O. Titus Wells has cared for all six of Bruce and Wendy Smith’s children. As a family physician whose practice includes obstetrics, Dr. Wells attended the births of all but one of the children. The Smiths’ 18-month-old daughter Ginny has had many ear infections. Even though this is a common problem, Dr. Wells finds that it presents a real medical challenge. Sometimes examination of Ginny’s ears indicates a raging infection and at other times shows the presence of middle ear fluid, which may or may not represent a bona fide bacterial infection. He tries to reserve antibiotics for clear-cut cases of bacterial otitis. He feels it is important that he be the one to examine Ginny’s ears because her eardrums never look entirely normal and he knows what degree of change is suspicious for a genuinely new infection.
When Ginny is 2 years old, Dr. Wells recommends to the Smiths that she see an otolaryngologist and audiologist to check for hearing loss and language impairment. The audiograms show modest diminution of hearing in one ear. The otolaryngologist informs the Smiths that ear tubes are an option. At Ginny’s return visit with Dr. Wells, he discusses the pros and cons of tube placement with the Smiths. He also uses the visit as an opportunity to encourage Mrs. Smith to quit smoking, mentioning that research has shown that exposure to tobacco smoke may predispose children to ear infections.
Barbara Starfield, one of the world’s foremost scholars in the field of primary care, conceptualized the key tasks of primary care as (1) first contact care, (2) longitudinality, (3) comprehensiveness, and (4) coordination. Dr. Wells’ care of the Smith family illustrates these essential features of primary care. He is the first-contact physician performing the initial evaluation when Ginny or other family members develop symptoms of illness. Longitudinality (or continuity) refers to sustaining a patient–caregiver relationship over time. Dr. Wells’ familiarity with Ginny’s condition helps him to better discern an acute infection. Comprehensiveness consists of the ability to manage a wide range of health care needs, in contrast with specialty care, which focuses on a particular organ system or procedural service. Dr. Wells’ comprehensive, family-oriented care makes him aware that Mrs. Smith’s smoking cessation program is an important part of his treatment plan for Ginny. Coordination builds upon longitudinality. Through referral and follow-up, the primary care provider integrates services delivered by other caregivers. These tasks performed by Dr. Wells meet the definition of primary care as defined by the Institute of Medicine: “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 sustained partnerships with patients, and practicing in the context of family and community” (Institute of Medicine, 1996).
A functional approach helps characterize which health care professionals truly fill the primary care niche. Among physicians in the United States, family physicians, general internists, and general pediatricians typically provide first contact, longitudinal, comprehensive, coordinated care. Emergency medicine physicians provide first contact care that may be relatively comprehensive for acute problems, but they do not provide continuity of care or coordinate care for patients on an ongoing basis. Some obstetrician-gynecologists provide first contact and longitudinal care, but usually only for reproductive health conditions; it is the rare obstetrician-gynecologist who is trained and inclined to comprehensively care for the majority of a woman’s health needs throughout the lifespan (Rivo et al, 1994). Similarly, a patient with kidney failure or a patient with cancer may have a strong continuity of care relationship with a nephrologist or an oncologist, but these medical subspecialists rarely assume responsibility for comprehensive care of clinical problems outside of their specialty area or coordinate most ancillary and referral services (Rosenblatt et al, 1998).
In addition to physicians, many generalist nurse practitioners and physician assistants in the United States deliver the four key Starfield functions and serve as primary care providers for their patients. Research performed in a selected number of practices have demonstrated comparable quality of care for patients treated by primary care physicians and nurse practitioners (Horrocks et al, 2002).
Studies have found that the core elements of good primary care advance the “triple aims” of health system improvement: better patient experiences, better patient outcomes, and lower costs (Starfield, 1998). For example, continuity of care is associated with greater patient satisfaction, higher use of preventive services, reductions in hospitalizations, and lower costs (Saultz and Albedaiwi, 2004; Saultz and Lochner, 2005). There is evidence that having a regular source of care results in better control of hypertension and less reliance on emergency department services (Shea et al, 1992). A Canadian study found that children undergoing tonsil-lectomy were more likely to have the operation performed for appropriate indications when they were referred to the otolaryngologist by a pediatrician than when care was directly sought from the otolaryngologist (Roos, 1979). Persons whose care meets a primary care–oriented model have better perceived access to care are more likely to receive recommended preventive services, are more likely to adhere to treatment, and are more satisfied with their care (Bindman et al, 1996; Stewart et al, 1997; Safran et al, 1998). International comparisons have indicated that nations with a greater primary care orientation tend to have more satisfied patients and better performance on health indicators such as infant mortality, life expectancy, and total health expenditures (Starfield et al, 2005). Within the United States, states with more PCPs per capita have lower total mortality rates, lower heart disease and cancer mortality rates, and higher life expectancy at birth compared with states having fewer PCPs, adjusting for other factors such as age and per capita income. In contrast, increases in specialist supply are associated with greater costs but not improved quality (Starfield et al, 2005). In an analysis of quality and cost of care across states for Medicare beneficiaries, Baicker and Chandra (2004) found that states with more PCPs per capita had lower per capita Medicare costs and higher quality. States with more specialists per capita had lower quality and higher per capita Medicare expenditures.
Polly Seymour, described earlier in the chapter, feels terrible. Every time she eats, she feels nauseated and vomits frequently. She has lost 8 pounds, and her oncologist is worried that her breast cancer has spread. She undergoes blood tests, an abdominal CT scan, and a bone scan, all of which are normal. She returns to her gastroenterologist, who tells her to stop the ibuprofen she has been taking for tendinitis. Her problem persists, and the gastroenterologist performs an endoscopy, which shows mild gastric irritation. A month has passed, $3000 has been spent, and Polly continues to vomit.
Polly’s friend Martha recommends a nurse practitioner who has been caring for Martha for many years and who, in Martha’s view, seems to spend more time talking with patients than do many physicians. Polly makes an appointment with the nurse practitioner, Sara Steward. Ms. Steward takes a complete history, which reveals that Polly is taking tamoxifen for her breast cancer and that she began to take aspirin after stopping the ibuprofen. Ms. Steward explains that either of these medications can cause vomiting and suggests that they be stopped for a week. Polly returns in a week, her nausea and vomiting resolved. Ms. Steward then consults with Polly’s oncologist, and together they decide to restart the tamoxifen but not the aspirin. Polly becomes nauseated again, but eventually begins to feel well and gains weight while taking a reduced dose of tamoxifen. In the future, Ms. Steward handles Polly’s medical problems, referring her to specialty physicians when needed, and making sure that the advice of one consultant does not interfere with the therapy of another specialist.
A concept that incorporates many of the elements of primary care is that of the primary care provider as gatekeeper. Gatekeeping took on pejorative connotations in the heyday of managed care, when, as described in Chapter 4, some types of financial arrangements with PCPs provided incentives for them to “shut the gate” in order to limit specialist referrals, diagnostic tests, and other services (Grumbach et al, 1998). A more accurate designation of the role of the PCP in helping patients navigate the complexities of the health care system is that of coordinator of care (Franks et al, 1992). Stories such as Polly’s demonstrate the importance of having a generalist care coordinator who can advocate on behalf of his or her patients and work in partnership with patients to integrate an array of services involving multiple providers to avoid duplication of services, enhance patient safety, and care for the whole person.
Dr. Retro is counting the days until he can retire from his solo practice of family medicine. He feels overwhelmed most days. The next available appointment in his office is in 10 weeks, and patients call every day frustrated about not being able to get appointments. A health plan just sent him a quality report card indicating that many diabetic patients in his practice have not achieved the targeted levels of control of their blood sugar, blood pressure, and lipids. He is also behind in keeping his patients up to date on their mammograms and colorectal cancer screening. Many days he has trouble finding information in the thick paper medical records about when his patients last received their preventive care services or diabetic tests. He was hoping to recruit a new family medicine residency graduate to take over his practice, but most young physicians in his region are pursuing more highly paid careers in non-primary care specialties.
Dr. Avantgard has always embraced innovation. When she read a series of articles in the Journal of the American Medical Association about new primary care practice models (Bodenheimer and Grumbach, 2007), she proposed to her 3 physician and 2 nurse practitioner partners that their primary care practice become a Patient Centered Medical Home. Dr. Avantgard starts by identifying a consultant to help the practice completely revamp their scheduling system to a “same-day” appointment system, where 50% of appointment slots are to be left unbooked until the day prior so that patients can call and be guaranteed a same day or next day appointment. Despite her partners’ concerns about being overrun with patient appointments, the new scheduling system results in the same number of patients being seen each day, but with happier patients who are delighted to be able to get prompt access to care. The practice buys an electronic medical record system and uses the EMR to develop registries of all the patients in the practice due for preventive and chronic care services. Dr. Avantgard and her associates train their medical assistants to use the EMR, along with standing orders, to proactively order mammograms and blood lipid tests when due and to administer vaccinations and screen for depression during patient intake at medical visits. Now that many of the routine preventive and chronic care tasks are being capably handled by other staff, Dr. Avantgard and her clinician colleagues have more time during office visits to focus on the problems patients want to talk with them about and to work through complex medical problems. With the quality indicators and patient satisfaction scores for the practice rising to the top decile of scores for practitioners in the region, Dr. Avantgard plans to start negotiations with several health plans to add a monthly care coordination payment to the current fee-for-service payments they pay, so that the practice can be compensated for all the work they perform in care coordination outside of office visits.
By the turn of the 21st century, primary care in the US had reached a critical juncture (Bodenheimer, 2006). In 2006, the American College of Physicians sounded the alarm about an “impending collapse of primary care medicine” (American College of Physicians, 2006). Primary care clinicians like Dr. Retro struggled to meet patient demands for accessible, comprehensive, well-coordinated care. Many gaps in quality existed, and care often fell short of being patient centered. PCPs were demoralized by outmoded practice models ill-equipped to meet the demands of modern-day primary care and an ever-widening gap between their take-home pay and the escalating earnings of specialists. In response to this crisis, the 4 major professional organizations representing the nation’s primary care physicians—the American Academy of Family Physicians, American College of Physicians, American Academy of Pediatrics, and American Osteopathic Association—came together in 2007 and issued a report on a shared vision for reform of primary care. The Joint Principles of a Patient-Centered Medical Home has served as a rallying point for building a broad movement to revitalize primary care in the US (Grundy et al, 2010).
The term “medical home” dates back to 1967, when it was first used by the American Academy of Pediatrics to describe the notion of a primary care practice that would coordinate care for children with complex needs. While the Joint Principles have several specific elements, Rittenhouse and Shortell (2009) have provided a straightforward conceptualization of the patient-centered medical home as consisting of four basic cornerstones: primary care, patient-centered care, new-model practice, and payment reform. This framework begins by reaffirming the fundamental functions of primary care and the goal of delivering accessible, comprehensive, longitudinal, and coordinated care. The concept then builds on those foundational principles by calling for greater attention to patient-centeredness, such as the type of same-day scheduling methods adopted by Dr. Avantgard; implementation of innovative practice models, such as Dr. Avantgard’s development of team-care models that reengineer workflows and tasks; and changes in physician payment, such as blending fee-for-service with partial capitation and quality incentives. Another perspective on the patient-centered medical home is shown in Table 5–2.
Table 5–2. “Old” and “new” model primary care: some elements of transforming a practice into a patient-centered medical home
The primary care reform movement in the United States has gathered momentum, with many large employers and consumer groups joining the physician organizations authoring the Joint Principles and other health professional groups to form the Patient Centered Primary Care Collaborative (Grundy et al, 2010). The Collaborative advocates and provides technical assistance for policy reforms to support primary care and transformation of practices into patient-centered medical homes. The push to enact the Affordable Care Act in 2010 focused lawmakers’ attention on primary care. President Obama and many members of Congress recognized that expanding insurance coverage requires an adequate primary care workforce to provide first contact care for millions of newly insured people. The Affordable Care Act includes several measures to strengthen primary care, including increases in Medicare fees for primary care and support of patient-centered medical home reforms. Evaluation of the first wave of practices and systems implementing the types of practice innovations called for under patient-centered medical home reforms have demonstrated improvements in patient satisfaction and quality of care and reductions in use of costly emergency department and hospital services (Grumbach and Grundy, 2010). Whether the new-found enthusiasm for reform and renewal of primary care can be sustained and lead to a fundamental reorientation of the health system in the United States remains to be determined.
The growth of the dispersed mode of health care delivery in the United States was shaped by several forces. One factor was the preeminence of the biomedical model among medical educators and young physicians throughout the 20th century. The combination of stricter state licensing laws and an influential national study, the Flexner report of 1906, led to consolidation of medical training in academically oriented medical schools (Starr, 1982). These academic centers embraced the biomedical paradigm that was the legacy of such renowned 19th-century European microbiologists as Pasteur and Koch. The antimicrobial model engendered the faith that every illness has a discrete, ultimately knowable cause and that “magic bullets” can be crafted to eradicate these sources of disease. Physicians were trained to master pathophysiologic changes within a particular organ system, leading to the development of specialization (Luce and Byyny, 1979).
Advocates of a larger role for generalism and primary care in US health care have not so much rejected the concepts of scientific medicine and professional specialism as they have attempted to broaden the interpretation of these terms. They have called for a more integrated scientific approach to understanding health and illness that incorporates information about the individual’s psychosocial experiences and family, cultural, and environmental context as well as physiologic and anatomic constitution (Engel, 1977). The attempt to more rigorously define the scientific and clinical basis of generalism contributed to the emergence of family medicine in the 1970s as a specialty discipline in its own right, and the 1-year general practice internship was replaced by a 3-year residency program and specialty board certification.
A second and related factor influencing the structure of health care was the financial incentive for physician specialization and hospital expansion, which played out in a number of ways.
1. Insurance benefits first offered by Blue Cross covered hospital costs but not physician visits and other outpatient services.
2. As physician services came to be covered later under Blue Shield and other plans, a growing differential in reimbursement between generalist and specialist physicians developed. New technologic and other procedures often required considerable physician time when first introduced, and higher fees were justified for these procedures. But as the procedures became routine, fees remained high, while the time and effort required to perform them declined (Starr, 1982); this resulted in an increasing disparity in income between PCPs and specialists (Bodenheimer et al, 2007). In the mid-1980s, the average PCP’s income was 75% of the average specialist’s income; by 2006, PCP income had dropped to only 50% of specialists’ income (Council of Graduate Medical Education, 2010). As Figure 5–2 shows, the percentage of graduating medical students planning to enter careers in primary care tracks the PCP-specialist income gap closely, with the proportion of students entering primary care decreasing as the earnings of PCPs relative to specialists declines.
Figure 5–2. Proportion of US medical students entering primary care strongly tracks relative incomes of primary care physicians. The figure shows trends over time in the average income of primary care physicians relative to specialist physicians in the United States, and in the percentage of graduating medical students in the United States planning on entering careers in primary care. In 1990, when the average primary care physician income was about half that of specialists, fewer than 20% of graduating students planned to enter primary care fields. By 1997, when primary care physician incomes had risen to more than 60% that of specialists, the proportion of graduating students entering primary care had increased in a parallel direction with 40% of graduates planning to enter primary care fields in 1997. Both relative incomes and intentions to enter primary care decreased after 1997. (From the Council on Graduate Medical Education. Twentieth Report: Advancing Primary Care, December 2010).
3. Federal involvement in health care financing further fueled the expansion of hospital care and specialization. The Hill–Burton Hospital Construction Act of 1946 allocated nearly $4 billion between 1946 and 1971 for expansion of hospital capacity rather than development of ambulatory services (Starr, 1982). The enactment of Medicare and Medicaid in 1965 perpetuated the private insurance tradition of higher reimbursement for procedurally oriented specialists than for generalists. Medicare further encouraged specialization through its policy of extra payments to hospitals to cover costs associated with residency training. Linking Medicare teaching payments to the hospital sector added yet another bias against community-based primary care training.
The growth of hospitals and medical specialization was intertwined. As medical practice became more specialized and dependent on technology, the site of care increasingly shifted from the patient’s home or physician’s office to the hospital. The emphasis on acute hospital care had an effect on the nursing profession comparable to that on physicians. World War I was a watershed period in the transition of nursing from a community-based to a hospital-based orientation. During the war, US military hospitals overseas were much heralded for their success in treating acute war injuries. At the war’s conclusion, the nation rallied behind a policy of boosting the civilian hospital sector. According to Rosemary Stevens (1989),
Before the war, public-health nursing was the elite area; nurses had been instrumental in the campaigns against tuberculosis and for infant welfare. In contrast, the war emphasized the supremacy and glamour of hospitals. . . . nurses, like physicians, were trained—and ready—to perform in an increasingly specialized, acute-care medical environment rather than to expand their interests in social medicine and public health (Stevens, 1989).
The final factor accounting for the organizational evolution of US health care delivery was the nature of control over health planning. The United States is unique in its relative laxity of public regulation of health care resources. In most industrialized nations, governments wield considerable control over health planning through measures such as regulation of hospital capacity and technology, allocation of the number of residency training positions in generalist and specialist fields, and coordination of public health with medical care services. In the United States, the government has provided much of the financing for health care, but without an attendant degree of administrative control. The Hill–Burton program, for example, did not make grants for hospital construction contingent upon any rigorous community-wide plan for regionalized hospital services. Medicare funding for physician training did not stipulate any particular distribution of residency positions according to specialty.
With government controls kept largely at bay, the professional “sovereignty” of physicians emerged as the preeminent authority in health care (Starr, 1982). Societies grant certain occupations special status as “professions” because of the unique knowledge and skill required of members of the profession, and the expectation that this knowledge and skill will be applied beneficially (Friedson, 1970; Light and Levine, 1988). Professionalism thus involves a social contract; in return for the privilege of autonomy, physicians bear the responsibility for acting as the patient’s agent, and the profession must regulate itself to preserve the public trust.
Their professional status vested physicians with special authority to guide the development of the US health care system. As described in Chapter 2, third-party payment for physician services was established with physician control of the initial Blue Shield insurance plans. Physician judgment about the need for technology and greater inpatient capacity drove the expansion of hospital facilities.
What was the nature of the profession that so heavily influenced the development of the US health care organization? It was a profession that, because of the primacy of the biomedical paradigm and the nature of financial incentives, was weighted toward hospital and specialty care. Small wonder that US health care has emphasized its tertiary care apex over its primary care base. In Chapter 16, we discuss the shifting power relationships in health care that are challenging the professional dominance of physicians.
Jeff leaves a town forum at the local medical center feeling confused. It featured two speakers, one of whom criticized the medical center as being out of touch with the community’s needs, and the other of whom defended the center’s contributions to society. Jeff found the first speaker very convincing about the need to pay more attention to primary care, prevention, and public health. He had never had a regular primary care physician, and the idea of having a family physician appealed to him. He was equally impressed by the second speaker, whose account of how research at the medical center had led to life-saving treatment of children with a hereditary blood disorder was very moving, and whose description of the hospital’s plan for a new imaging center was spellbinding. Jeff felt that if he ever became seriously ill, he would certainly want all the specialized services the medical center had to offer.
The professional model and the biomedical paradigm are responsible for many of the attractive characteristics of the US health care system. The biomedical model has instilled respect for the scientific method and has helped to curtail medical quackery. Professionalism has directed physicians to serve as agents acting in their patients’ best interests and has made the practice of medicine more than just another business. Expansion of hospital facilities has meant that people with health insurance have had convenient access to tertiary care services and new technology. Patients have been able to take advantage of the expertise and availability of a wide variety of specialists. In many circumstances, the system is well organized to deliver the “right care.” For a patient in cardiogenic shock, the right place to be is an intensive care unit; for a patient with a detached retina, an ophthalmologist’s office is the right place to be.
However, there is widespread concern that despite the benefits of biomedical science and medical professionalism, the US health care system is precariously off balance. A model of excellence focused on specialization, technology, and curative medicine has led to relative inattention to basic primary care services, including such needs as disease prevention and supportive care for patients with chronic and incurable ailments. The value placed on individualism and autonomy for health care professionals and institutions has contributed to a pluralistic delivery system in which care is often fragmented and lacking coordination. A system that prizes specialists who focus on organ systems and researchers who concentrate on splitting genes has bred apprehension that health care has somehow lost sight of the whole person and the whole community. The net result is a system structured to perform miraculous feats for individuals who are ill, but at great expense and often without satisfactorily attending to the full spectrum of health care needs of the entire population. During the 2009 debate in Congress leading up to the passage of the Affordable Care Act, one of the harshest critiques of the status quo in US health care came not from a Congressional Democrat, but from Senator Orrin Hatch, the senior Republican Senator from Utah. At a hearing on health reform, Senator Hatch said, “The US is first in providing rescue care, but this care has little or no impact on the general population. We must put more focus on primary care and preventive medicine. How do we transform the system to do this?” (Grundy et al, 2010).
Akinbami LJ et al. Status of childhood asthma in the United States, 1980–2007. Pediatrics. 2009;123(Suppl 3):S131-45.
American College of Physicians. The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care. January 30, 2006. http://www.acponline.org/advocacy/events/state_of_healthcare/statehc06_1.pdf.
Baicker K, Chandra A. Medicare spending, the physician work-force, and beneficiaries’ quality of care. Health Aff (Millwood). 2004:W4-184.
Bindman AB et al. Primary care and receipt of preventive services. J Gen Intern Med. 1996;11:269.
Bodenheimer T. Regional medical programs: No road to regionalization. Med Care Rev. 1969;26:1125.
Bodenheimer T. Primary care—will it survive? N Engl J Med. 2006;355:861.
Bodenheimer T et al. The primary care-specialty income gap: Why it matters. Ann Intern Med. 2007;146:301.
Bodenheimer T, Grumbach K. Improving Primary Care. Strategies and Tools for a Better Practice. New York, NY: McGraw-Hill; 2007.
Council on Graduate Medical Education. Twentieth Report: Advancing Primary Care, December 2010.
Dawson W. Interim report on the future provision of medical and allied services. In: Saward EW, ed. The Regionalization of Personal Health Services. London, England: Prodist; 1975.
Engel GL. The need for a new medical model: A challenge for biomedicine. Science. 1977;196:129.
Franks P et al. Gatekeeping revisited: Protecting patients from overtreatment. N Engl J Med. 1992;327:424.
Friedson E. Professional Dominance: The Social Structure of Medicine. Atherton, CA: Atherton Publishing; 1970.
Fry J. Primary care. In: Fry J, ed. Primary Care. London, England: William Heinemann; 1980.
Green LA et al. The ecology of medical care revisited. N Engl J Med. 2001;344:2021.
Grumbach K, Grundy P. Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of Evidence From Prospective Evaluation Studies in the United States. Washington, DC: Patient Centered Primary Care Collaborative, 2010. http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf.
Grumbach K et al. Primary care physicians’ experience of financial incentives in managed care systems. N Engl J Med. 1998;339:1516.
Grumbach K et al. Regionalization of cardiac surgery in the United States and Canada: Geographic access, choice, and outcomes. JAMA. 1995;274:1282.
Grundy P et al. The multi-stakeholder movement for primary care renewal and reform. Health Affairs. 2010;29:791.
Halvorson GC, Isham GJ. Epidemic of Care. San Francisco, CA: Jossey-Bass; 2003.
Horrocks S et al. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324:819.
Institute of Medicine. Primary Care: America’s Health in a New Era. Washington, DC: National Academies Press; 1996.
Light D, Levine S. The changing character of the medical profession: A theoretical overview. Milbank Mem Fund Q. 1988;66:10.
Luce JM, Byyny RL. The evolution of medical specialism. Perspect Biol Med. 1979;22:377.
Rivo ML et al. Defining the generalist physician’s training. JAMA. 1994;271:1499.
Rodwin VG. The Health Planning Predicament. Berkeley, CA: University of California Press; 1984.
Roos N. Who should do the surgery? Tonsillectomy-adenoidectomy in one Canadian province. Inquiry. 1979;16:73.
Rosenblatt RA et al. The generalist role of specialty physicians: is there a hidden system of primary care? JAMA. 1998;279:1364.
Safran DG et al. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213.
Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: A critical review. Ann Fam Med. 2004;2:445.
Saultz JW, Lochner J. Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med. 2005;3:159.
Shea S et al. Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population. N Engl J Med. 1992;327:776.
Somers AR. Who’s in charge here? Alice searches for a king in Mediland. N Engl J Med. 1972;287:849.
Starfield B. Primary Care. New York, NY: Oxford University Press; 1998.
Starfield B et al. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457.
Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982.
Stevens R. In Sickness and in Wealth: American Hospitals in the Twentieth Century. New York, NY: Basic Books; 1989.
Stewart AL et al. Primary care and patient perceptions of access to care. J Fam Pract. 1997;44:177.
Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514.
White KL et al. The ecology of medical care. N Engl J Med. 19; 265:885.