As health care costs and the nation’s ranks of uninsured continue to vie for the title of scariest rate of growth, a group of TAFP members have been meeting with managed care leaders to explore ways that family medicine could come to the rescue. Here’s their pitch.

By Richard Young, M.D.

I was talking with an acquaintance named Joe recently and he looked preoccupied. Joe owns several restaurants in the North Texas area and has about 100 employees. He has invested in information systems to make his operation as efficient as the latest technology will allow. He puts in as many hours as we physicians, but he still feels that for every two steps forward he takes three back.

He tries to be a conscientious employer, searching for a balance between the needs of his family, his company and his employees. He provided health insurance to all levels of management at his restaurants until the cost became too high. Nearly 10 years of double-digit inflation finally forced Joe to eliminate health insurance as a covered benefit for all but the executive employees. He understood the burden this would place on the younger employees, especially those with small children, but the solvency of the business he had nurtured over the last 20 years was at stake.

Joe’s is not an unusual story. Different versions of this scenario echo across America in large and small companies. Efficiencies that have been realized in many businesses, often through the use of information technology, have not translated into higher wages or more jobs. These gains are being pulled into the enormous financial black hole of health care, despite the increased cost burden shifted to most employed Americans over the last five years. The number of uninsured in America continues to rise both in absolute numbers and as a percentage of working adults.

The primary concern of Americans today in the arena of health care is not safety or quality, according to a recent poll by the Kaiser Family Foundation. Americans are not so much worried that the wrong body part will be cut off, but that they can’t afford the surgery.

The number one problem with American health care is that it costs too much and TAFP understands this. Under the leadership of TAFP President-elect Doug Curran, M.D., a group of us have met with the Texas leadership of Blue Cross/Blue Shield to discuss these very difficult issues. A refreshingly open and friendly atmosphere has surrounded our discussions of these enormous and complex issues.

Talks with BC/BS have been our first steps, but they won’t be our last. We plan to meet with just about anyone who will listen. Meetings with Medicaid and other private insurers such as Aetna are in the planning stages. The purpose of this article is to make known to the broad TAFP membership the specific points we are making to the payers. Our message is simple: American health care costs too much and family medicine is the answer.

Family Medicine, Costs, Quality and Outcomes

Several studies have appeared on the radar screens of policy makers who examine health care costs, quality and outcomes. The one that seems to be getting the most attention appeared in Health Affairs, entitled “Medicare Spending, the Physician Workforce and Beneficiaries’ Quality of Care” by Baicker, et al, which examined the costs and quality outcomes for Medicare beneficiaries. The researchers gathered data at the state level on how often Medicare beneficiaries received commonly accepted interventions such as mammograms, flu shots, diabetic retinopathy screening, ACE inhibitors for patients with systolic heart failure, etc. Each state and the District of Columbia were ranked according to an overall quality score. They also gathered data on the amount of money Medicare spends per beneficiary each year and its relationship to the number of family physicians and the number of specialists per capita for each state.

Findings revealed that as the specialist supply increased, the cost per beneficiary also increased but the overall quality score decreased. As the family physician supply increased, the cost per beneficiary decreased and the overall quality score increased.

Other recently published studies have found that counties with more primary care physicians have lower mortality rates; states with more primary care physicians have lower rates of death from stroke, infant mortality and all-cause mortality; and the odds of finding breast, cervical, colon and skin cancers at an early stage increase as the supply of family physicians increase.

These studies remind us of what over 20 years of health services literature has consistently found: family physicians deliver care for patient populations that is of equal or higher quality than specialists at similar or lower costs.

The Quad/Graphics Experiment

We have used an article from The Wall Street Journal by Vanessa Fuhrmans in our discussions with BC/BS that illustrates the cost-effectiveness of a true primary care-based delivery system. Fuhrmans reports the experience of a printing company in Wisconsin called Quad/Graphics where the staff, tired of double-digit medical inflation, decided to take matters into their own hands.

Quad/Graphics hired family physicians, internists and pediatricians directly and put them in clinics at the factories. The physicians see one patient every half hour and work on salary with the opportunity to get bonuses for meeting outcome goals. They use an electronic health record.

According to The Wall Street Journal, the company spends more on primary care, $715 per employee versus $375 at other local employers. As a result of their investment in primary care they have lower hospital costs ($1,540 per employee per year versus $2,250), less cost inflation (0.75-percent decrease in 2003 and 1-percent increase in 2004), and lower overall costs ($6,000 per employee per year, which is 30 percent less than the average company in Wisconsin).

John Neuberger, the business manager for Quad’s medical division told The Wall Street Journal, “What we’ve learned here is that when primary care is done right, the results can be amazing.”

What Explains the Difference?
It’s Probably Not What You Think

When asked what explains the lower costs experienced by patient populations that rely more on family physician care, most family physicians and policy makers would probably answer, “prevention.” Family physicians feel that prevention is one of their bedrock principles, and as everybody knows “an ounce of prevention is worth a pound of cure.”

Actually, in terms of health care costs and outcomes, nothing could be further from the truth. In almost every instance, to test for an asymptomatic disease or to vaccinate an adult to prevent a disease, a better adage might be: an ounce of prevention costs a ton of money.

Let’s look at the costs and outcomes of a commonly accepted preventive intervention, the tetanus shot. If we wanted to vaccinate all Texans who are not currently immunized, it would require about 10 million shots. Let’s assume they cost $5 per dose without considering the marketing and advertising expenses it would require to bring patients into our offices. In this scenario, we spend about $50 million to eliminate tetanus from Texas.

What did we really achieve? Each year about six Texans acquire tetanus and one person dies from it. Let’s assume it costs $100,000 to care for each tetanus victim. We would spend $600,000 per year or $6 million over 10 years to prevent 10 deaths from tetanus. Bottom line, we spent $50 million to save $6 million. Ten years later the longevity of the vaccination is exhausted and we have to revaccinate everyone. The savings in reduced tetanus cases would never catch up to the front-end costs of the vaccination.

This is not to suggest that we should stop vaccinating our patients against tetanus. The point is that this measure of prevention doesn’t save health care costs. Most other commonly accepted interventions cost more on the front end than they save by reduced disease burden, see Table 1.

If Not Prevention, Then What?

This is where the literature is somewhat lacking. Part of the problem is that only paltry funding for primary care research exists. Another part is that the answer is inherently complex. Still, we can make some educated guesses.

In our presentation to BC/BS, we used an example in our presentation that went like this: imagine there is a 48-year-old diabetic woman who developed one month of increasing weakness, fatigue, shortness of breath and chest tightness. Oh by the way, she reports some marital stress and also her son needs a camp physical and is out of his asthma medication.

We presented two scenarios. In the first, the woman went to her family physician under a “primary care preferred” plan with comprehensive primary care reimbursement. In the second, the woman went to a variety of specialists who each dealt with only the complaint associated with their favorite organ system. The costs and outcomes are shown in Tables 2 and 3.

The punch line of the scenarios was that the woman made one trip to her family physician, who addressed her health care needs, diagnosed her with depression and started a treatment regimen, and took care of her son’s needs, all in one visit. In the multi-organ scenario, she made eight trips, spent 10 times as much and no doctor diagnosed her depression.

How many times have you seen segments on talk shows or read newspaper articles that go something like this: I suffered with (insert symptoms here) for years. My GP gave me a few different prescriptions, but nothing seemed to work. I finally called Dr. Sub Specialist who ran a battery of tests and diagnosed me with (insert disease here). I am finally receiving proper treatment for (insert disease here) and I finally feel great again.

Does this actually happen? It must. There are too many anecdotes in the press to deny that specialists occasionally diagnose patients with rare conditions that family physicians miss.

But how often have you seen the following scenario? A cardiologist writes post-catheterization orders and does not resume any of the non-cardiac medications. An OB-GYN orders a thousand dollars worth of hormone levels in a patient that clearly has the signs and symptoms of a mood disorder. A psychiatrist orders drug levels on every patient to catch the rare slow metabolizer, when a brief conversation with the patient would determine that the patient is experiencing medication side effects. A patient goes to any single-organ doctor and reports symptoms in a different part of their body and the only action taken by the physician is to tell them to make an appointment with another single organ doctor.

Which scenarios happen more often? The macroscopic evidence indicates that the process errors and zebra chases carried out in a multi-doctor patient care model create more errors and expensive inefficiencies than the number of errors and oversights that occur in a generalist patient care model.

The TAFP Message

Our overall conclusion is this: we believe that the frequent observation that family physicians deliver higher quality care at a lower cost than the multi-physician approach can be explained by at least four factors.

1. Family physicians are better at triaging complex information.
2. Family physicians are more efficient at managing patients with chronic diseases.
3. Family physicians are better able to work up new symptoms in a timely and efficient manner.
4. Family physicians are better able to utilize their long-term relationships with their patients to achieve these efficiencies.

Our message to the payers is as follows:

• Family physicians realize that the enormous cost of health care is creating financial, emotional and physical hardships and is consequently reducing the quality of life for millions of Americans.
• Family-physician-directed care has been shown repeatedly to deliver better outcomes at a lower cost.
• For a true family-physician-directed model of care to work, family physicians must actually be paid for their work. The evaluation and management payment system must be adjusted to allow family physicians to fully express the different cognitive tasks we perform and most importantly, to get paid for all of them.

  A study by J.W. Beasley and published in the September/October 2004 Annals of Family Medicine found that a family physician addresses an average of three problems per visit. Thirty-seven percent of encounters addressed more than three problems while 18 percent addressed more than four problems. The current evaluation and management system allows physicians to bill for no more than two problems at one visit. Clearly family physicians can’t express the full extent of services we provide on our bills.

• Family medicine wants to be an integral part of the solution to the high cost of health care.
• We want to maintain a dialogue with all involved parties: national, state and local governments; insurance companies; employers; other physicians; other health care workers; and most importantly, our patients.

We hope this article has stimulated some thought and maybe even some action. Please send your thoughts to Jonathan Nelson, jnelson@tafp.org, at TAFP on how we can improve the health status of our patients by making family medicine the centerpiece of health care in America.