Improve care, lower costs

Americans like to complain about the healthcare system, but they're unnerved by many of the proposals for improving it. More than 90% of those surveyed last fall by the Deloitte Center for Health Solutions said that healthcare costs are a threat to their personal financial security, and 80% gave the system a mediocre grade or worse. Yet less than half favored measures to promote electronic medical records, the use of scientifically proven treatments or more monitoring of the safety and effectiveness of drugs. Evidently, we'd rather live with the shortcomings we know about than risk more severe ones.

One encouraging thing about healthcare reform, however, is that improving the quality of care can help slow the debilitating increase in costs. It's good for all. And although the changes required won't be easy, they're essential to the crucial third piece of the healthcare reform puzzle, which is providing coverage to all Americans.

Healthcare providers, academics, analysts and insurers agree that the starting point to improving quality is in adding to the ranks of primary-care doctors and giving them a more proactive role in maintaining their patients' health. According to the American Academy of Family Physicians, other industrialized nations have found that adding one primary-care physician for every 20,000 people decreased the number of unexpected premature deaths by 9%. It also decreased hospitalizations and reduced the amount of care required for many ailments. It's not enough, though, just to have more of these doctors; they also need to expand their contacts with patients, promoting healthy behavior, managing chronic conditions and coordinating the care delivered by specialists, clinics, hospitals and other parts of the healthcare system. Such coordination is rare outside of tightly integrated providers such as the Mayo Clinic, and quality suffers as a result.

The main reason for the shortage of primary-care doctors is that Medicare, Medicaid and private insurers don't pay enough for the work they perform. The current system generally reimburses providers for what they do to their patients, not how well their patients stay, which means it undervalues immunizations, routine checkups and other services that can ward off or mitigate ailments. As Dr. Ted Epperly, president of the family physicians group, has noted, insurers will pay a lot to amputate the leg of a diabetic patient, but not so much to provide the services that might have prevented the amputation. Consequently, the U.S. has a lower percentage of primary-care physicians (about 30%) than other industrialized nations. Worse, the number of med-school graduates choosing primary-care fields is declining rapidly, dropping by half since 1997.