Why Are We a ‘Loss Leader’ for Procedural Subspecialties?



Kenneth W. Lin, MD, MPH

Hi, everyone. I’m Dr Kenny Lin. I am a family physician at Georgetown University Medical Center, and I blog at Common Sense Family Doctor.

By the time you read these words, I will be in the process of leaving my practice of the past decade and relocating from Washington, DC, to Lancaster, Pennsylvania. Although 10 years is hardly a long time to practice family medicine in the same place, this upcoming transition has caused me to reflect on primary care policy developments during that time. Earlier this year, I spoke with the former American Academy of Family Physicians (AAFP) President, Reid Blackwelder, MD, about why he remains hopeful about the future of primary care despite staff shortages, financial challenges, and burnout that the COVID-19 pandemic exacerbated for many. Not only does primary care turnover interrupt patient care continuity, it costs public and private payers almost $1 billion in excess healthcare expenditures annually, according to a recent study.

In the past few years, The Lancet, the AAFP, and others have urged US policymakers to make strengthening primary care a priority to improve health outcomes and health equity. Largely because of the income gap between primary care physicians and subspecialists, the percentage of medical students who match into family medicine residency programs has been flat for the past 10 years. To improve working conditions, the AAFP supports replacing single, disease-oriented, burdensome quality measures that payers currently use to assess value with a person-centered primary care measure that captures comprehensiveness, first contact access, coordination, and continuity of care.

In a previous Medscape commentary, I asserted that having health insurance improves health and lowers mortality because it provides people with access to primary care. Two recent reports from the Commonwealth Fund illustrate, however, that our primary care system lags far beyond those from ten other high-income countries. The first report found that US adults were the least likely to have a long-standing relationship with a primary care doctor or usual source of care, and they were the least likely to be able to receive primary care at home or after hours. Lower-income US adults also reported worse health status and primary care access than did lower-income adults in other high-income countries.

A second report compared to international health status and healthcare quality for women of reproductive age. Women of reproductive age have always comprised a significant percentage of my patients and those of my family medicine colleagues. In this report, US women outranked only Swedish women in the percentage of those without a regular doctor or place of care; were near the worst in out-of-pocket spending; were the most likely to skip needed care because of cost; and were the most likely to have problems paying medical bills. It is no surprise that the United States also had the highest rates of avoidable deaths and maternal mortality.

I wish I could say that family medicine in particular and primary care in general are in a better position today to solve our country’s multiplying health woes than when I started seeing patients in my current practice in 2012. The truth is, I am not sure that is the case. I have little doubt that I will eventually establish the kind of trusting relationships with patients in my new practice that have made practicing family medicine so rewarding. But until the US government and healthcare systems start recognizing primary care as a common good rather than a “loss leader” for procedural subspecialties, there will never be enough generalists like me to achieve the superior outcomes that are possible in countries with high-performing primary care.

Kenny Lin, MD, MPH, teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is the deputy editor of the journal American Family Physician.

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