Please, Sir, may I have some more…?
Charles Dickens’s words spoken through the orphan boy Oliver Twist have melted hearts generation after generation. Now, most Americans — rural citizens, especially — could make this plea:
Please, Uncle Sam, we do not want to be orphans. We want our primary health care clinics back.
The United States spends $2 trillion on health care annually — nearly $7,000 per person.
Alternatively, we could be building a stronger, cheaper, more efficient health care system based on an old model that worked well: rural family practice clinics. In the current lingo, this time-tested approach is being called calls ” a continuity primary care home.” It’s the latest fad for workforce leaders; and where it has not been extinguished by current health policy, it is also the oldest, most effective, and essential health access vehicle.
A “continuity primary care home” brings a patient to one location over time for primary care from a general practice physician working with a primary health care team. It’s what a rural family doc or rural family practice clinic has always been. But the fact is that kind of “old-fashioned” health care practice has all but disappeared. Instead, what we have are fewer physicians of any kind in rural areas, more and more temps, specialists, urgent care and emergency practitioners: a high-priced health care system that fails to meet our most elemental needs.
How much would a reasonable beginning toward a system of these clinics cost? We could devote $26 million a year for physicians that start in continuity homes and stay there. This would cost a paltry sum — just over $11 per person per year (we’re comparing that with $7000 per person, remember).
For this bread and water ration of $26 million, here’s what the United States would receive:
- About 600 more family-physician graduates a year specifically admitted for health access, trained for health access, and supported to remain in health access. The 600 per year would be trained for seven years with a focus on health access with the final five years of training in locations in need of primary care physicians.
- About 18,000 more standard primary care years (30 SPC years per family medicine graduate). The 600 annual graduate physicians will do more good for our nation’s health than do the current 8000 internal medicine graduates that have such poor retention in primary care. Over time, these six hundred family physicians will deliver the same amount primary care that will be delivered by 6500 physician-assistant graduates (as in 2008) or 6500 nurse practitioner graduates of 2008.
“Please, sir, I want some more…” can result in our getting more for less.
To deliver primary care, graduates must stay in primary care and not depart during training, at graduation, or after graduation.
- The 600 family physicians are just 2% of the physicians entering the US workforce. Yet among the class of 2020, this 2% will deliver 10% of the primary care.
- This 2% will meet 25% of the primary care needs the United States population that’s now left behind with deficient primary care, due to the current health policy design. This is the 65% of the population with only 23% of physicians.
- This 2% of entering physicians will supply 35% of the primary care for underserved populations, half serving urban underserved and half serving rural underserved populations.
Under this system there would be equitable care for rural populations, for underserved populations — the poor, near poor, and minorities, as continually documented by studies of family physician. Rural areas would benefit, with family physicians three times more likely to be found in rural locations and increasing to greater levels for the most isolated and underserved settings.
One would think that a good deal for the elderly rural population, and for the nearly 65% of Americans left behind, would be something our country would embrace. It is a good deal for Alaska’s clinics attempting to care for those most left behind, as savings with continuity home family physicians have been substantial compared to locums (substitute physicians) or temporary obligation physicians. About 20 family physicians a year in Alaska save about $10 million a year in locums, recruitment, retention, state, and federal costs over the current situation, as the nation graduates the fewest doctors for rural, underserved, and family medicine careers.
If instituted, continuity health clinics could be one of few economic recovery vehicles that has a chance of serving the 65% of Americans now left behind in health, economic development, jobs, and other benefits. “Please Sir, may I have some more….?” so we can all do more with less in the future.
For more see the report U.S. Rural Physician Workforce: Analysis of Medical School Graduates from 1988-1997, prepared by scholars at University of Washington. Most MDs, doctors of osteopathy (DOs) and International Medical Graduates (IMGs) go to work in urban settings, according to this research charting where physicians who graduated between 1988 and 1997 have gone into practice.