A Call for a New Society: Marshaling Primary Care's Power

Brian Klepper, PhD

Disclosures

July 25, 2012

Introduction

The dream of reason did not take power into account -- modern medicine is one of those extraordinary works of reason -- but medicine is also a world of power.
Paul Starr, The Social Transformation of American Medicine (1984)

How can primary care's position be reasserted as a policy leader rather than a follower?

Even though it is a linchpin discipline within America's health system and its larger economy -- a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs -- primary care has been overwhelmed and outmaneuvered by a healthcare industry intent on freeing access to lucrative downstream services and revenues.

That compromise has produced a cascade of undesirable effects that reach far beyond healthcare. Bringing American healthcare back into homeostasis will require an approach that appreciates and leverages power in ways that are different from those of the past.

But primary care also has complicity in its own decline. It has been largely ineffective in communicating and advocating for its value and in recruiting allies who share its interests. Equally important, it has failed to appreciate and protect primary care's foundational role in US healthcare and the larger economy, as well as the advocacy demands of competing in a power-based policy environment.

What Has Been the Result?

The consequences have been withering constraints that have diminished primary care's value and thwarted its roles as first-line manager of most medical conditions and patient-advocate and guide for downstream services. Combined with fee-for-service reimbursement and a lack of cost/quality transparency, primary care's waning influence has precipitated a cascade of effects, allowing health industry revenues to grow at more than 4 times the general inflation rate for more than a decade,[1] with unnecessary utilization and cost that credible estimates suggest accounts for at least half of all healthcare spending.[2]

These effects have been catastrophic not only for primary care physicians, but also for patients, who are routinely exposed to unnecessary medical risks, and for purchasers, who for decades have borne an unnecessarily onerous economic burden. It seems unlikely that these groups' prospects can improve without a meaningful change in the strategy pursued by primary care's leading organizations.

The State of Primary Care

Primary care is a demoralized medical specialty. Recent Medscape data show that, on average, generalists make about half what their specialist colleagues do. Other surveys are more pronounced. A 2010 Graham Center study calculated a $3.5 million career income difference between primary care and specialist physicians.[3]

None of this is lost on medical students. Faced with skyrocketing training debt, few now opt to make significantly less, so the percentage selecting primary care has plummeted. Between 1990 and 2007, the percentage of internal medicine residents becoming generalists dropped by 80%.[4]

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