Viewpoints

Twenty-five years ago, the Institute of Medicine (now known as the National Academy of Medicine) exposed serious failures of US healthcare and declared that the system was so flawed it couldn’t be fixed—it needed to be replaced. That, of course, didn’t happen. For the past twenty-five years, our efforts have continued to focus on fixing a broken system. 

 

While patches of various sorts have been tried, interval policy reports have articulated numerous major redesign opportunities, such as bringing physical and mental healthcare together as integrated care, reuniting primary care and public health with communities, bringing intelligent thought and planning to produce the health professions workforce that communities need, and, most recently, rescuing primary care as a public good instead of a neglected service line.  Most of these opportunities remain fallow.

 

Meanwhile, the U.S. health system has evolved into a financial juggernaut, powering the economy while spending incomprehensible amounts of money for occasional miracles and mostly mediocre to poor measured outcomes of access, quality, and affordability.  The US now has the most expensive healthcare in the world, capable of stunning achievements for some while neglecting many.

 

Almost three years after the National Academy of Medicine published “Implementing High Quality Primary Care: Rebuilding the Foundation of Health Care,” the Milbank Memorial Fund and the Robert Graham Center have published a further report card on how the United States is doing in rebuilding primary care, aiming to hold us accountable for actually doing something to implement genuine primary care for all.  Their message? Primary care is still collapsing, a not-so-slow motion disaster.

 

If primary care is struggling, then it’s no surprise that US healthcare is struggling too. We’ve seen remarkable positive effects, documented for decades, of how primary care actually improves individual and population health, addresses disparities, and contains costs.  But what is the reality of US healthcare?  Relentless increases in expenditures crowding out alternative investment opportunities, difficulties accessing care, unconscionable disparities in health, decreasing lifespans, and widening gaps between what other peer nations achieve and the US. 

 

There is hope, however. This new report card doesn’t only report bad news. It points the way forward: 

• Stop starving primary care and finance it—increase primary care funding from 4-6% of healthcare expenditures to 10-12%.
•  Link everyone to a usual source of care where they are known by name and can bring any concern.
• Grow the primary care workforce fast enough to meet population needs and prepare clinicians in the communities they will serve. 
• Replace burdensome technologies that distract from comprehensive, relationship-based care with enabling technologies that support continuity relationships.
• Make it possible to get most care close to home.
• Buttress evidence-based primary care practice with a major investment in practice-based evidence generated by a properly funded and guided research and implementation enterprise.  
  

   

   

All of this could be initiated immediately—if the country decides we want to work together to assure primary care for all and invest in it as a public good.

 

This is a policy emergency hiding in plain sight. 

 

Let’s study the Milbank-Graham Center report and share it locally, particularly with policymakers and secondary and tertiary care health professionals where we live, work, and play.  Let’s keep sounding the alarm and join with others (e.g.  www.primarycareforallamericans.org) to rescue collapsing primary care and rebuild it into an amazing foundation of better health and healthcare for all.  

 

I recently sat in a virtual primary care leadership meeting with probably 40 people attending. (There were too many little Zoom boxes to count.)

 

I watched a PowerPoint presentation in which a table outlining what primary care clinicians do was shared. The people presenting had boiled down “primary care provider clinical activity” to things that could be counted: individual direct clinic sessions, consults for things that I consider to be specialty care that live in our primary care clinics (but that is another story), time spent reviewing charts, participating in huddles, typing notes, answering portal messages, etc. This list of activities was intended to account for “providers’” productivity to help leaders in our system understand, value, and account for the work our clinicians do.

 

To me, primary care is a function that is at the foundation of peoples’ personal health and the health of our communities. By the end of the presentation, with its accounting list, my heart was aching.

 

Primary Care and the Personal Clinician

 

The function of primary care is to provide whole-person care. Primary care clinicians are generalists who address the majority of people’s health needs throughout their lifespan, not just for a set of specific diseases. The function of primary care is to ensure people receive comprehensive care: prevention, treatment, rehabilitation, pre- and post-natal care, including the birth of babies, as well as end-of-life care.

 

This function is inseparable from the function of a personal clinician who is also a generalist. A personal clinician has a committed trusting relationship with patients. It is in the context of a patient’s relationship with a personal clinician, preferably over the course of a lifespan, that whole person, comprehensive care health care is realized. As described by T.F. Fox in 1960:

 

A person in difficulties wants in the first place the help of another person on whom [they] can rely as a friend—someone with knowledge of what is feasible but also with good judgment on what is desirable in the particular circumstances, and an understanding of what the circumstances are. The more complex medicine becomes, the stronger are the reasons why everyone should have a personal doctor who will take continuous responsibility for [them], and, knowing how [they] live, will keep things in proportion—protecting [them], if need be, from the zealous specialist. The personal doctor is of no use unless [they] are good enough to justify [their] independent status. An irreplaceable attribute of personal physicians is the feeling of warm personal regard and concern of doctor for patient, the feeling that the doctor treats people, not illnesses, and wants to help [their] patients not because of the interesting medical problems they may present but because they are human beings in need of help.¹

 

 

From Accounting to Accountability

 

I spoke up in the meeting to explain how I was feeling in response to the accounting list devoid of the foundational functions of both primary care and the personal primary care clinician. My comments, while eventually appreciated, were initially dismissed as “qualitative” wh(ich was the ideal way to dismiss me, a qualitative researcher).

 

The system in which I work is not the only one where primary care clinicians are being pushed toward accounting for what they do. But what is needed instead is a focus on clinician accountability to the people and communities they care for as healers. I stole the title of this blog post from someone I greatly admire, Carlos Jaen, who recently made a similar point about this on a national listserv.

 

This suggests to me that my system and the clinicians I work with are not alone in struggling with accounting versus accountability. But why was I – the non-clinician in the virtual room – the only one who spoke up? Why did I watch as my clinician colleagues put additional countable items in the chat? How do we help our primary care clinician leaders, who I respect and value greatly, shift their way of seeing and thinking about their work so that they can lead our health systems in a new direction, one that moves away from accounting and toward accountability and responsibility?

 

Reference

 

1. Fox TF. The personal doctor and his relation to the hospital. Observations and reflections on some American experiments in general practice by groups. Lancet. 1960 Apr 2;1(7127):743-60.

My wife and I live in a community in the midst of 700 acres of prairie and a hundred-acre organic farm. The founders designed it thirty-five years ago to be a conservation community with a fixed number of houses. Nothing has been built since 1995. Someone from a neighboring community asked my wife if we live in “the place where no one cuts their lawns.” Yes, that’s us. Our lawn is small and our yard has lots of prairie, full of flowers and grasses which go from our yard, over hills, and down into a lake.

Every spring and fall, cadres of community members join to burn the prairie. Seeing six-foot grasses and flowers burn over hundreds of acres with people walking along with water tanks on their backs and wet brooms to keep it under control is extraordinary. Science and tradition know that burning helps seed dispersal, helps native plants get a head start next year, and rids the prairie of debris and invasive species, enabling early stronger growth of natives.[1] Fire opens the landscape to grass and flowers, and its ashes nurture plants in the future. Every few years, after a burn, a newly grown, stronger prairie is subjected to wind, rain, snow and sun.

Graduate education in family medicine, like a neglected and unburned prairie, has the potential to get overgrown and tangled up, losing the ability to adapt to a changing environment. Residency education could use a good burn.

Without it, sticking new plants into already packed soil or hoping that old ideas that need revival will suddenly thrive is hopeless. Healthy prairies are harbingers of a changing environment. Education should be as well. But without periodic burns, they both will deteriorate.

Having a bonfire of residency documents is not what I am suggesting, although many people I know would welcome such an event. We need intellectual fires to weed, promote growth, and diversify.

Creating an Academic Prairie Fire

Every 5 years, every residency program in the country should set an Academic Prairie Fire. Make it a celebration of renewal.

• Start with discussing basic principles - the native plants - such as continuity and comprehensiveness of care, the creation of relationships, and keeping a generalist perspective on the work of medicine.
• Faculty members can review the changing profiles of their patient population, the circumstances of their communities, and gather information about forces for health and illness that affect them.
• A structured conversation among clinicians, staff(both clinical and educational), residents, and fellows, which takes stock of how well the program is supporting the native plants - adhering to its guiding principles - should guide decisions about what to change or delete and what to reinforce and expand.
• Then, gather with community and patient advisory boards, asking them what they think about what the program has found. Asking the communities in which we work what they see as important factors for health and illness is essential to partnering with those communities. [2]

Then light the match and begin the renewal. Don’t tweak things, burn them.

Renewing a residency program every five years should regrow necessary core training while weeding out non-native plants, i.e., those that don't serve family medicine's basic principles, and seeding the ground with new adaptable ideas for environmental changes in education. If curriculum is essential to what family physicians will be doing in ten years, it stays; if not, other curriculum replaces it.

For example, decades of dealing with addiction disorders requires more creativity and time from education than simply learning how to prescribe suboxone. [3] Before the pandemic, virtual care was a small part of practice, patient care at home and communities was discouraged, and public health partnerships were few and far between. Now those ideas are essential to the future roles for family doctors in practice. But squeezing new curriculum between hospital and specialty rotations probably won’t work.

Renewal of Faculty and Curriculum

Faculty members need renewal as well. The tradition of sabbatical was intended to permit faculty members to spend time away and come back with new ideas for courses, research, or teaching. Sabbaticals in medical schools are rare and primarily taken by senior faculty members. [4] But achieving the competence and creativity to be an effective teacher in new structure with new content requires more than a weekend workshop.

A post-Academic Prairie Fire residency program will require faculty members with new attitudes and who are eager to teach new material in new ways. With time and space, new ideas can thrive. Renewal guards against stale teachers and stale ideas. Many will focus on the risks involved in radical renewal, advocating for stability and measured change. But fifty years of measured change have left the discipline with decreasing interest from medical students and exhausted clinicians and educators.

Finally, an Academic Prairie Fire will push the renewal of education where medicine is practiced. The need for adaptability both of curriculum and teachers has never been more important. But, as Jason wrote: “Many of us are inclined to put our trust in practices that have been done for a long time, seldom asking if there was a sound rationale for starting them in the first place. Resistance to recommended changes is common in human institutions.”[5] Change will not be easy. Dropping aspects of current curriculum that do not represent what family doctors will be doing in five years will take courage, commitment and resistance to forces of standardization.

The central goal of residency education is to become a good doctor, of course, but also to become a better and more skilled doctor who understands and embraces change in society and uses it to improve health. Family medicine residency education should create working relationships with community services, public health, and school systems, analyze the morbidity and mortality statistics from the community and respond to their needs, and partner to create programs to address them. Social isolation, disaffected young people, drug use, unsafe schools, isolated elderly, disabilities, and mental health issues can’t just be add-ons. Physicians will need to leave the comfort of hospitals and clinics and go into schools, workplaces and become advocates for marginalized people of all types.

All this will take time. The discipline needs to demand the time to reflect and change – to recover from the fire – by taking control of residency education so that innovation, creativity and renewal of teachers and curriculum can take place and be evaluated appropriately.

Blooming

Prairies and wild lands will not disappear but are constantly threatened. Their health in great part depends on principles of conservation and renewal. Healthy environments stay healthy through adaptation, not stagnation, just as intellectual diversity depends on creative destruction that allows persistence of core ideas while letting new ideas bloom.

A regular Academic Prairie Fire would be a wonder to behold and a time of real excitement. Renewal would energize teachers, create a true learning community and focus on innovation both in education and clinical care.[6] Renewal would also assure that family medicine education would be of its time and place, not trapped in its past.

References

Ratcliffe H, Ahlering M, Carlson D, Vacek S, Allstadt A, Dee LE. Invasive species do not exploit early growing seasons in burned tallgrass prairies. Ecol Appl. 2022;32(7):e2641.

Murray SA, Tapson J, Turnbull L, McCallum J, Little A. Listening to local voices: adapting rapid appraisal to assess health and social needs in general practice. BMJ (Clinical research ed). 1994;308(6930):698-700.

Loxterkamp D. Helping 'them': our role in recovery from opioid dependence. Annals of Family Medicine. 2006;4(2):168-171.

Robiner WN, Buum HT, Eckerstorfer M, Kim MH, Kirsch JD. Sabbaticals in US Medical Schools. The American Journal of Medicine. 2023;136(3):322-328.

Jason H. Future medical education: Preparing, priorities, possibilities. Medical Teacher. 2018;40(10):996-1003.

Newton W, Fetter G, Hoekzema GS, Hughes L, Magill M. Residency Learning Networks: Why and How. Annals of Family Medicine. 2022;20(5):492-494.

David Cooperrider, co-creator and thought leader of Appreciative Inquiry, famously declared, “Human systems grow in the direction of questions they most persistently and frequently ask themselves.”  

The current US healthcare system continues to grow in the direction of the questions asked by the mammoth medical industrial complex. These questions are often about: 

• Growth of the enterprise
• Optimization of service lines
• Securing margins, pricing, efficiency.

Miraculous rescues of individuals from the ravages of biology run amok and violent accidents compel questions about how humans might rescue more people by:

• Taking control of homo sapiens’ genetic structure and improving it to relieve pain and suffering, 
• Modifying cellular biology to precisely attack cancer cells 
• Marshalling machines to supply vital functions and to learn from large language databases.  
  

Ten Questions We Need to Ask

I suggest that these questions are insufficient to compel growth of a future healthcare system suitable to meeting the needs of people.  
What other questions might be asked to inspire us to revise or replace current systems to create the best healthcare ever?  Here’s a list of ten:

1. What is the purpose of healthcare as exhibited by the current system and what should it be going forward?
2. What makes healthcare meaningful to the general public and to healthcare professionals?
3. What values provide a foundation for healthcare and what makes healthcare valuable?
4. Where and how is health won and lost?
5. Where is healthcare best provided?
6. What organizational and structural principles can/should inform a next generation healthcare system?
7. Can competition and collaboration be promoted simultaneously in healthcare? If so, how? 
8. How can the magnificence of each individual be honored in highly personalized healthcare?
9. What social compact can/should unite healthcare professionals and the individuals, families and communities they pledge to serve?
10. Will people have a personal physician in the future and, if so, what will these physicians do?
    

What questions are more important than these?

In the iconic 1976 movie, “Network,” a veteran news anchor, fed up with life and the state of the world, calls on viewers to fight for change. “First, you’ve got to get mad,” he cries. “You’ve got to say, I’m a human being. And goddammit, my life has value.” He encourages people to open their windows and yell, "I'm as mad as hell, and I'm not going to take this anymore!"

After decades as observers, participants, and researchers in health care, we are fed up with America’s healthcare system. It’s a powerful medical industrial complex designed to produce wealth, not health, and it’s time for us - we the people - to demand change. Here’s why.

A $5,000,000,000,000 Investment

A recent report from the Centers for Medicare & Medicaid Services estimates that 2024 healthcare spending will exceed $5 trillion dollars for a population of 335 million people, more than $15,000 per capita.[1] (See Table A) Five trillion is a hard number to grasp. Five trillion seconds is almost 160,000 years. A country with a $5 trillion GDP would be the third largest economy on earth.[2] Yet the US will spend this on healthcare in a single year. 

What’s more, healthcare spending is increasing rapidly. Compared to 2023, spending by private insurance is estimated to grow by more than 8 percent this year and spending by Medicare by more than 6 percent. The burden of this spending falls not only on private businesses and federal, state, and local governments; about 1/3 of 2024 national healthcare expenditures (approximately 1.7 trillion dollars) is estimated to come from US household budgets. (See Table B.) Despite this abundant spending, 24 million people lack health insurance, and that number is expected to top 30 million in just eight years.[1] 

What kind of country spends so much on healthcare and leaves so many without reliable access to it?

The reality is that the healthcare sector of the US economy represents livelihoods for a substantial workforce and revenues for powerful interests that influence health policy. (See Table C.) Altering this unsustainable trajectory would threaten many and provoke resistance from current beneficiaries. Yet not changing a trajectory that consistently outpaces growth of the entire US economy crowds out other important social needs in areas including energy, climate change, transportation, education, social services, and defense. Indeed, whether this spending on healthcare is channeled through insurance, taxes, charitable giving, employers, or out-of-pocket payment, all health care expenditures are comprised of OUR money. 

Return on Investment

What are we getting for our exorbitant investment? Life expectancy is a hard-edged and important health outcome. In the US, life expectancy dramatically increased from 47 years in 1900 to 68 years in 1950 and 79 years in 2019. (Partly because of the COVID-19 pandemic, life expectancy dropped in 2021 to 76 years, rising in 2022 to 77.5 years.) Health care deserves some credit for this mostly upward trend.

What these numbers don’t reveal, however, is the persistent and growing gap between life expectancy in the US and peer nations: “During 1933 to 2021, 56 countries on 6 continents surpassed US life expectancy. . . The US life expectancy disadvantage began in the 1950s and has steadily worsened over the past 4 decades.”[3]  Another objective measure of the health of a population is maternal mortality, which has worsened in the US and is much higher than in other countries, with wide differences amongst Black, Hispanic, and white women in the US.[4]

What kind of country settles for such mediocre performance of its healthcare system?

Restoring Healthcare’s Purpose

If the purpose of healthcare is to generate expenditures and wealth for some, our spending and spending increases are good news. However, if its purpose is to improve individual and population health, it is bad news indeed. Given the amount of money we devote to healthcare, almost certainly the issue is how we organize and spend it and for what purpose: wealth or health? 

The current system – the US medical industrial complex – is powerful and holds sway over our legislative and executive branches of government. Is there a source of power sufficient to restore the purpose of healthcare as health instead of wealth? 

Yes. “We the people” of the United States could unite and re-examine what it takes to improve health across all communities: urban, suburban, and rural; red, blue, and purple. 

An important explanation for the mortality disadvantage lies in, 1) failing to address social influencers of health, 2) our persistent underinvestment in public health, mental and behavioral health, and 3) our underinvestment in primary care, the evidence-based foundation of better, sustainable healthcare systems.  According to the Medical Expenditure Survey, primary care spending in 2019 was $439 per person, only 7% of medical spending. Nearly 41% of the population had zero primary care spending.[5] This matters because decades of research have established that properly delivered primary care improves healthcare and individual and population health while containing costs and relieving disparities in access and outcomes[6]—exactly the effects the US urgently needs.

Where does the rest of the money go? (See Table D.)

The National Academy of Medicine has reviewed the evidence and declared, disturbingly, that US primary care is collapsing and needs leadership and capitalization for its reform into the information age.[6] No wonder so many of us are finding it so hard to find a good doctor, a welcoming place where we can present any personal health issue and know we will be heard and helped.

How do we fix this?

“We the People” Must Take Action

Fortunately, the National Academy of Medicine has provided authoritative and actionable recommendations to establish primary care as a common good, something to which we all need access, like roads, public safety, and clean water.[6] They have also established a standing committee to guide policy revisions to buttress and modernize primary care with vital connectivity to public health and mental health. 

The stage for action is set.  

To build a strong and resilient foundation of primary care requires great resources and evidence-based policymaking.  Investing in restoring our nation’s primary care foundation is a fundamental, enabling step for reorganizing healthcare, and it’s a step we can take right now. In the richest country on earth, doing so will transform a dysfunctional system into one that serves all of us. 

Together, we the people are a source of power that can bring about change. We must demand an overhaul of our under-performing, fragmented healthcare system, a system that has been distracted by pursuit of wealth rather than health. We must tell policymakers and legislators, from city councils and mayors to federal officials, that it’s time to stop spending more and getting less.

Let’s get mad as hell, open our windows and yell loud enough for everyone to hear: We want action on healthcare as if our lives and the lives of our loved ones depend on it, because they do.



References:
1. Jacqueline A. Fiore, Andrew J. Madison, John A. Poisal, Gigi A.Cuckler, Sheila D. Smith, Andrea M. Sisko, Sean P. Keehan, Kathryn E. Rennie, and Alyssa C. Gross. National Health Expenditure Projections, 2023–32: Payer Trends Diverge As Pandemic-Related Policies Fade. Health Affairs 43, No.7.  Published online June 12,2024.  https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2024.00469  accessed 7/2/24
2. Worldometer. Sources: World Bank (Development indicators July 25, 2023; United Nations (World Population Prospects 2022). https://www.worldometers.info/gdp/gdp-by-country/, accessed 7/2/24.
3. Woolf SH. The growing gap in life expectancy between the US and other countries, 1933-2021. AJPH 2023.  Published online August 9, 2023 https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2023.307310, accessed 7/2/24.
4. The Century Foundation. The Worsening U.S. Maternal Health Crisis in Three Graphs.  https://tcf.org/content/commentary/worsening-u-s-maternal-health-crisis-three-graphs/, accessed 7/2/24.
5. Decker SL, Zuvekas SH. Primary Care Spending in the US Population. JAMA Intern Med. 2023;183(8):880-881. doi:10.1001/jamainternmed.2023.1551, accessed 7/11/24.  
6. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Implementing High-Quality Primary Care; Linda McCauley, Robert L. Phillips, Jr., Marc Meisnere, and Sarah K. Robinson, Editors. 2021. https://nap.nationalacademies.org/catalog/25983/implementing-high-quality-primary-care-rebuilding-the-foundation-of-health, accessed 7/11/24.

Table A:	Expected Healthcare Expenditures in 2024
US Gross Domestic Product (GDP)	$28.5 trillion
National Health Expenditures (NHE)	$5.049 trillion (5.2% more than 2023)
NHE % of GDP	17.7%
NHE per capita	$15,074
Personal Health Care Expenditures	$4.8 trillion
Out of pocket Expenditures	$542 billion

 

Tabe B:	Sources of National Health Expenditures (100%)
Private Business	18% $908 billion
Households	29% $1.44 trillion
Federal Government	30% $1.53 trillion
State/Local Government	16% $806 billion
Other	7%

 

Table C:	Three Insurers’ Expenditures (% growth over 2023, % increase per enrollee)
Private insurance	$1.550 trillion (8.1% growth, 6% per enrollee)
Medicare	$1.086 trillion (6.1% growth, 4% per enrollee)
Medicaid	$833 billion (-2.2% growth,10% per enrollee)

 

Table D:	Where does the money go? (% increase over 2023)
Hospitals	$1.56 trillion (4.6%)
Physicians	$1.01 trillion (4.9%)
Dentists	$185 billion (5.2%)
Nursing Homes/Retirement Com	$216 billion (3.3%)
Home care	$155 billion (6.6%)
Retail sales medical products	$676 billion (6.9%)
Prescription Drugs	$463 billion (6.8%)
Government Administration	$58 billion (2.4%)
Net Cost of Insurance	$328 billion (7.3%)
Non-commercial research	$71 billion (4.8%)
Public Health Activities	$165 billion (0.5%)