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Fam medicine making the case andrew bazemore

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Fam medicine making the case andrew bazemore

  1. 1. Making the Case: Family Medicine for America’s Health Andrew Bazemore, MD, MPH Director, Robert Graham Center Family Medicine Congressional Conference, 2014
  2. 2. Definers of Primary Care, Family Medicine, and its essential role • 1920s: Dawson Report, U.K. • 1960s: Millis, Willard, Folsom Reports – US • 1970s: Lalonde Report, Canada Centerville WATER CONTROL COMMUNITY OF SOLUTION COUNTY LINE STATE LINE AIR POLUTION COMMUNITY OF SOLUTION MEDICAL TRADE AREA Cityville Medical Center TOWN LINE Figure 1. One city’s communities of solution. Political boundaries, shown in solid lines often bear little relation to a community’s problem-sheds or its medical trade area.
  3. 3. 1978: Declaration of Alma Ata “Primary care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individual and families in the community through their full participation and at a cost that the community and country can afford… It forms an integral part of both the country‟s health system, of which it is the central function and main focus, and overall social economic development of the community
  4. 4. Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Primary care is the “logical foundation of an effective health care system,” and, “essential to achieving the objectives that together constitute value in health care.” Institute of Medicine, 1996
  5. 5. How does health in the US compare? World Health Organization, 2000 Report • Country DALE Rank Overall Rank • France 4 1 • Japan 9 10 • UK 24 18 • Cuba 36 39 • Canada 35 30 • US 72 37 2008 World Health Report: Primary Care – Now more than Ever
  6. 6. Evidence supporting need to support PC prior to reform : Expenditures vs Primary Care Score UNITED STATES AUSBEL GER CAN DKFIN NTH SPA SWE UK FRA JAP $0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500 $4,000 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 worse Primary Care Score better PerCapitaHealthCare Expenditures2000 Adapted with permission from Starfield B. Policy relevant determinants of health: an international perspective. Health Policy 2002;60:201-21. United States AUS BEL GER CAN FIN SP SWE UK 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 11 12 better------Primary care score ranking-------worse HealthcareOutcomes Rank* NTH/DK
  7. 7. The State of our Primary Care Workforce: Best of Times?
  8. 8. Historical perspective suggests longterm boom: Phys/Pop Ratios 1980-2010 LAURA A. MAKAROFF, DO; LARRY A. GREEN, MD; STEPHEN M. PETTERSON, PhD; and ANDREW W. BAZEMORE, MD Am Fam Physician. 2013 Apr & Sept:online.
  9. 9. Or worst of Times? 13
  10. 10. Needing 52,000 more… 14
  11. 11. ACA impacts demand differently across states: PC Supply and Uninsurance 15 AL AK AZAR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY 5060708090 100 5 10 15 20 25 Percent Uninsured
  12. 12. Rapid NP/PA Growth
  13. 13. Comprehensiveness?:Trends in the Reported Care of Children by FPs 17
  14. 14. The Health of the Training Pipeline & Primary Care
  15. 15. Growing: An era of Allopathic, Osteopathic, (and offshore) expansion
  16. 16. But what will all this growth yield?
  17. 17. Student Interest • General Internal Medicine 2.0% • Med/Peds 2.7% • Family Medicine 4.9% • General Pediatrics 11.7% • Total: 21.3% K. E. Hauer et al. Choices Regarding Internal Medicine Factors Assoc With Medical Students' Career JAMA. 2008;300(10):1154-1164
  18. 18. .2.3.4.5.6 1980 1985 1990 1995 2000 2005 Medical School Year Of Graduation Allopathic Osteopathic Trends in Production of Primary Care, by School Type
  19. 19. .2.3.4.5.6 1980 1985 1990 1995 2000 2005 Medical School Year Of Graduation Allopathic Osteopathic Trends in Production of Primary Care, by School Type
  20. 20. .2.3.4.5.6 1980 1985 1990 1995 2000 2005 Medical School Year Of Graduation Private International Public Trends in Production of Primary Care, by School Type
  21. 21. Few Primary Care, 26% remain in Wide variation in outcomes
  22. 22. Many Primary Care, 54% remain in state
  23. 23. Such variability should be more transparent (www.medschoolmapper.org)
  24. 24. And what of Graduate Medical Education?
  25. 25. M. H. Ebell. Future Salary and US Residency Fill Rate RevisitedJAMA. 2008;300 GME Follows Green($) What Teaching Hospitals Do Anesthesiology (21%) Dermatology (40%) Radiology (25%) Ophthalmology (12%) Family Medicine (-4%) Pediatrics (-8%) General Internal Medicine (2%) -30 -20 -10 0 10 20 30 0 100000 200000 300000 400000 500000 2007 Median Specialty Income PercentChangeinNumberofPY-1 Available What Teaching Hospitals Do Weida, Bazemore, Phillips, Archives Internal Med, 2010 Income change adjusted for inflation 1998-2007
  26. 26. $0 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 AnnualIncome Year Driving force: Specialty to PC PaymentGap Diagnostic Orthopedic Surgery Primary Care Family Medicine
  27. 27. $13 billion in public investment for what? (GME Outcomes Study) We examined current practice for all 2006-08 grads: • Avg overall primary care production rate: 25.2%. • 759 sponsoring institutions, 158 produced 0 PC graduates, 184 (small) produced more than 80%. • 4.8% of graduates practiced in rural areas – 198 institutions produced no rural physicians, – 283 institutions produced no Federally Qualified Health Center or Rural Health Clinic physicians. • Additional studies underway – – Does training in a high cost area yield high cost physicians? – What additional institutional factors explain this variation in training outcomes?
  28. 28. And again, the outcomes vary widely Primary Teaching Site Name (ACGME) # Grads # Spec # PC % PC 138. Duke University Hospital 861 71 77 8.94 139. Northwestern Memorial Hospital 722 39 64 8.86 140. Baylor University Medical Center 170 16 15 8.82 141. Vanderbilt University Medical Center 775 55 67 8.65 142. Medical Center of Louisiana at New Orleans375 27 32 8.53 143. Cleveland Clinic Foundation 761 55 64 8.41 145. Brigham and Women's Hospital 844 40 69 8.18 146. Temple University Hospital 429 27 34 7.93 147. Thomas Jefferson University Hospital 515 43 37 7.18 148. Tulane University Hospital and Clinics 382 31 27 7.07 149. University of Chicago Medical Center 523 44 35 6.69 150. Massachusetts General Hospital 842 42 55 6.53 151. Stanford Hospital and Clinics 623 49 29 4.65 152. Johns Hopkins Hospital 848 70 39 4.6 153. Barnes-Jewish Hospital 848 50 30 3.54 154. Harper-Hutzel Hospital 244 17 5 2.05 155. Indiana University Health University Hospital411 27 3 0.73 156. NYU Hospitals Center 352 29 2 0.57 157. Mayo Clinic (Rochester) 243 30 0 0 158. Memorial Sloan-Kettering Cancer Center 169 10 0 0 John Peter Smith, #6, 44% PC; lots of FPs serving Texas
  29. 29. And should be transparent… Residency Footprinting Tool
  30. 30. So other than reduce the payment gap, what can we do? $0 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 AnnualIncome Year Driving force: Specialty to PC PaymentGap Diagnostic
  31. 31. Redistribution of slots to date has failed • 2003, Medicare Modernization Act – Redistributed nearly 3000 GME slots – Goal: Benefit Primary Care & Rural – Our findings: • Only 12 of 300 hospitals recipients of slots are rural, only 3% of all slots are rural • Redistributed slots = 2:1 Specialty:Primary Care
  32. 32. Decentralized Training Works
  33. 33. What trains in Vegas… stays in Vegas?
  34. 34. Rural Training Tracks • 18 going on 30, small but efficient producers Our evaluation shows: • 76% of grads practicing in the 13 states with RTTs at the time of study • >50% wkg in Rural (2-3x average for FP programs; far beyond the 4.8% of all GME grads working rural in our national study of all specialties (Acad Med 2013) • 48% in FQHC/RHC/CAH • 41% in HPSAs, Yr 1 post grad
  35. 35. Failing to extend and expand on GME gains (PCEP, THC) would signal little commitment to rehabilitate a failing pipeline
  36. 36. Our future must be team-based, and integrated with Public, Community and Behavioral Health • http://www.annfammed.org/content/10/3/250 .full
  37. 37. And we remain the frontline for many Americans
  38. 38. We need change facilitators, and data systems forward that serve integration, and primary care
  39. 39. And remember…to most Policymakers: Primary Care remains a Solution • Starfield (and many others): – Systems built around primary care have • Lower costs • Higher quality • Broader access • The ACA endorsed this solution, and widely expanded the number of Americans with „a card‟ • Remind policymakers where most care, particularly complex care, is occurring, and that real access requires „a card and a home‟
  40. 40. 1000 people 800 have symptoms 327 consider seeking medical care 217 physician’s office 113 primary care 65 CAM provider 21 hospital clinic 14 home health 13 emergency 8 hospital <1 academic health center hospitalNew Ecology of Medical Care – 2000, NEJM In an average month:
  41. 41. √ Health Insurance √ Usual Source of Care √ Health Insurance NO Usual Source of Care NO Health Insurance √ Usual Source of Care NO Health Insurance NO Usual Source of Care
  42. 42. And Care of Complex Chronic Disease is mostly taking place in that Home…
  43. 43. Remembering our roots 1978: Declaration of Alma Ata “Primary care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individual and families in the community through their full participation and at a cost that the community and country can afford… It forms an integral part of both the country‟s health system…and overall social economic development of the community
  44. 44. Final Thoughts • Primary Care is needed, “Now More than Ever”, and your Advocacy on its behalf is essential and appreciated • We exist to support your efforts with evidence, and more information is readily available at www.graham-center.org
  45. 45. Who We Are: A Family of Primary Care Scholars • 115 Larry A. Green Visiting Scholars • 12 Robert L. Phillips Policy Fellows – Dr. Laura Makaroff, now a Medical Officer for HRSA Bureau of Primary Care Georga Cooke "Community Competence" and Geography University of Queensland (Australia) Jennifer Voorhees Improving Primary Care Physician Compensastion Thomas Jefferson University Patricia Stoeck The Medical Home and Health Care Transition Counseling for Youth with Special Health Care Needs Georgetown University Erica Brode Primary Care in the ACO University of California, San Francisco Amy Marietta Primary Care and Health Care Access in Western North Carolina University of North Carolina at Chapel Hill Mark Stoltenberg Evaluating Educational Health Centers Loyola University Chicago Roxanne Richards Rhode Island: A Brief State of the State University of Virginia Questions?

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