As is common in government programs, expenditures for Medicare have risen sharply in recent decades. Medicare spending was merely $37 billion in 1980, but ballooned to $440 billion by 2007. Driving the increase in expenditures is an expansion of Medicare enrollees, which grew 51% between 1980 and 2006, while the US population grew by only 30% during this time. Additionally, rapid growth of technology and the development of advanced, specialized forms of medicine have driven up all health care costs.
With Census predictions showing that Medicare enrollment will continue to accelerate in coming decades, and with ever further advancements in medical care, total Medicare expenditures are predicted to explode. How can we continue to deliver care to an ever-growing population of older adults, while reining in costs? One outstanding way to improve the way we care for older people, and simultaneously reduce costs, is to increase the numbers of well-trained primary care physicians who attend to Medicare patients.
Abundant objective evidence shows that appropriate primary care, such as that provided by a family practice physician, a general internist, or a geriatrician, limits Medicare expenditures while simultaneously improving health outcomes. Older Americans who are burdened with multiple chronic diseases benefit the most from comprehensive primary care, because a primary care physician can coordinate treatments and avoid specialist interventions. Given that the bulk of Medicare expenditures go to those patients with multiple chronic diseases, ensuring an adequate supply of primary care doctors is now more important than ever.
Unfortunately, trends over the past decade show that number of doctors entering the primary care workforce is falling precipitously. US-trained doctors are being driven away from primary care, mostly because of high work loads and low compensation as compared to many medical subspecialties. Of those doctors who trained in internal medicine, only 20% remain as primary care practitioners today, as compared to 50% a decade ago. Similarly, the percentage of US-trained doctors in family practice residencies has fallen from 80% to 50%, in just 10 years. Hence, at a time when high-quality primary care is most needed, the number of physicians who are willing to do the task of primary care is shrinking rapidly.
The average number of family practice physicians per 10,000 population is the US is only 3.3 per 10,000. States that have more family practice physicians per capita – say 4-5 per 10,000 people – have substantially lower Medicare costs and improved health outcomes. It is estimated that if we simply increased the density of family practice doctors by 1 per 10,000 population, then we could decrease Medicare expenditures by 9%.
Ironically, Medicare is currently under-investing in primary care. Estimates of payments to primary care physicians show that only 4% of the budget goes to these doctors. Conversely, savings to Medicare that are imparted by primary care physicians range from 9% - 30% of the total Medicare budget. Direct ways to increase the numbers of primary care doctors include increasing the numbers of family practice residency training positions (which Medicare supports), and increasing remuneration to primary care doctors for office visits. Enacting these two simple measures would cost Medicare on the order of 1-2% of the total budget, but expected savings windfalls would be vastly greater. Both for the health of Medicare enrollees, and for the financial health of the Medicare system, it is necessary to increase the numbers of primary care providers in America.
Clearly, if we do not reverse current trends in primary care, then we will not have enough physicians to care for the burgeoning numbers of elderly and Medicare enrollees. With numbers of US-trained physicians in primary care dropping sharply, at exactly the time when the US population is becoming more elderly and more burdened with chronic disease, we are headed for a “perfect storm” in US healthcare. In order to reverse the worrying trends in primary care, Medicare needs to act to retain primary care physicians, and to recruit more doctors to the primary care field. If we do not, then health care costs will rise ever more quickly, as older and sicker patients receive progressively inferior care, and their illnesses become more costly to treat.
Dr. Niklason is a Professor of Anesthesia and Biomedical Engineering at Yale University. She is a world leader in the development of advanced cell therapies for cardiovascular disease.
