Visualizing Primary Care, Policy & Reform · Expenditures vs vs Primary Care Score UNITED STATES BEL AUS GER CAN FIN DK NTH SPA SWE UK FRA JAP $0 $500 $1,000 $1,500 …

Visualizing Primary Care, Policy & Visualizing Primary Care, Policy & ReformReform

Andrew Bazemore MD MPHAndrew Bazemore MD MPH

APHCRI-RGC Visiting

Fellowship

Senator DaschleSenator Daschle: : ““Other countries starts at the Other countries starts at the base of the pyramid with primary care, and they base of the pyramid with primary care, and they work their way up until the money runs out.work their way up until the money runs out.””

3° Care

1° Care

2° Care

3° Care

2° Care

1° Care

… “We start at the top of the pyramid, and we work our way down until the money runs out…And so we have to change the pyramid. We have to start at the base.”

International Comparison of Spending on Health, International Comparison of Spending on Health, 19801980––20052005

0

1000

2000

3000

4000

5000

6000

7000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

0

2

4

6

8

10

12

14

16

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Source: Commonwealth Fund; OECD Health Data 2007, Version 10/2007 .

Average spending on health per capita ($US PPP)

Total expenditures on health as percent of GDP

4

Expenditures Expenditures vsvs Primary Care ScorePrimary Care Score

UNITED STATES

AUSBEL

GERCAN

DKFINNTH

SPASWE 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 2worse Primary Care Score better

Per

Cap

ita H

ealth

Car

e Ex

pend

iture

s 20

00

Adapted with permission from Starfield B. Policy relevant determinants of health: an international perspective. Health Policy 2002;60:201-21.

Presenter

Presentation Notes

Adapted with permission from Starfield B. Policy relevant determinants of health: an international perspective. Health Policy 2002;60:201-21.

PrimaryPrimary--care score care score vsvs health outcomeshealth outcomes

UnitedStates

AUS

BEL GER

CANFIN

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-------worseH

ealth

care

Out

com

es

Ran

k* NTH/DK

*Rank based on patient satisfaction, expenditures per person, 14 health indicators, and medications per person in Australia, Belgium, Canada, Denmark, Finland, Germany, Netherlands, Spain, Sweden, United Kingdom, United States

Adapted with permission from Starfield B. Is primary care essential? Lancet 1994;344:1129-33.

Preventable DeathsPreventable Deaths

US is last among industrial nations in preventable deaths (ranked 19th )

Could prevent 100,000 deaths annually

Health Affairs, Sept, 2006

Mortality Amenable to Health CareMortality Amenable to Health Care U.S. Rank Fell from 15 to Last out of 19 CountriesU.S. Rank Fell from 15 to Last out of 19 Countries

7681

88 8489 89

99 9788

97

109 106116 115 113

130 134128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150

Fran

ceJa

pan

Austra

liaSpa

in

Italy

Canad

aNor

wayNeth

erlan

dsSwed

enGre

ece

Austri

aGer

many

Finlan

dNew

Zeala

ndDen

mark

United

King

dom

Irelan

dPor

tuga

lUnit

ed S

tates

1997/98 2002/03

Deaths per 100,000 population*

* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease.Source: Commonwealth Fund; E. Nolte and C. M. McKee, Measuring the Health of Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1):58–71

How do we rate?How do we rate? World Health Organization, 2000 ReportWorld Health Organization, 2000 Report

CountryCountry DALE RankDALE Rank Overall RankOverall RankFranceFrance 4 4 11JapanJapan 99 1010UKUK 2424 1818CubaCuba 3636 3939CanadaCanada 3535 3030

USUS 7272 3737Level of Health=25% Distribution of Health=25% Level of Health=25% Distribution of Health=25% Level of Responsiveness=12.5% Level of Responsiveness=12.5% Distribution of Responsiveness=12.5% Fairness of financing=25%Distribution of Responsiveness=12.5% Fairness of financing=25%

Health ReformHealth Reform……The American WayThe American Way

Presenter

Presentation Notes

Sausage making quote Stakeholder interests dominate the landscape

Zero Sum GameZero Sum Game

What is on the policy radar for What is on the policy radar for primary care in the U.S.?primary care in the U.S.?

Growing Consensus among US Growing Consensus among US policymakers around Primary Care policymakers around Primary Care

ReformReformPipelinePipeline

Workforce & TrainingWorkforce & Training

Payment ReformPayment ReformPCMHPCMH

Reorganization around a Patient Centered Reorganization around a Patient Centered Medical HomeMedical Home

CholskiCholski, NEJM 11/09, NEJM 11/09

Reforming the PC WorkforceReforming the PC Workforce……or or who will you find in the Medical who will you find in the Medical

Home?Home?

Primary Care WorkforcePrimary Care Workforce

1 FP/GP for every 3,081 persons1 FP/GP for every 3,081 persons1 general internist per 2,443 adults1 general internist per 2,443 adults1 general pediatricians for 1,548 children 1 general pediatricians for 1,548 children and adolescentsand adolescents238,939 primary care physicians238,939 primary care physicians

1 for every 1,260 persons1 for every 1,260 persons

Presenter

Presentation Notes

UPDATED: Dodoo – 11.27.07 Source: 1) AMA Masterfile, Sept 2007 2) US Census Bureau, http://www.census.gov/ Message: Of these actively practicing physicians, a little more than 1/3 (about 239,000) were primary care physicians, with there being a primary care PHYSICIAN for approximately about every 1,260 persons in the United States. There was a family physician in active practice for every 3000 persons, a general internist for about every 2400 adults, and a general pediatrician for about every 1500 children and adolescents. How many do we need? More information can be found at: http://www.graham-center.org/PreBuilt/physician_workforce.pdf Note: Associated log and syntax file: g:\rgcdata\unwted\ama\prg\summary.sas

Physician to Population Ratios Physician to Population Ratios 19801980--20062006

(Physicians per 100,000 persons)(Physicians per 100,000 persons)

0

50

100

150

200

250

300

1980 1985 1991 1995 2000 2005 2006

Phys

icia

ns (M

D) p

er 1

00,0

00 p

erso

ns

All physicians Sub-Specialists Primary care physicians

Presenter

Presentation Notes

Updated: Dodoo – 3-20-2007 Data sources: 1. Number of physicians (MD only) 1980 to 1995 from http://bhpr.hrsa.gov/healthworkforce/reports/factbook02/FB202.htm 2. Relevant population numbers from U.S. Census Bureau, Statistical Abstract of the United States: 2006, Section I, http://www.census.gov/prod/2005pubs/06statab/pop.pdf, Tables 2 and 11 and from U.S. Census Bureau, Statistical Abstract of the United States: 2000, Section I, http://www.census.gov/prod/2001pubs/statab/sec01.pdf, Table No. 12 3 Number of physicians (MD and DO) 2000 and 2005 from AMA Master Files, SAS programs at g:\rgcwork\Data_slide_update\data\prg\summary1.sas 4. Number of osteopathic physicians 1980 - 1995 from American Osteopathic Association, Publications Division, AOA Fact Sheet, June 2000 http://www.osteopathic.org/pdf/ost_factsheet00.pdf - Calculations on doc_popln_ratios spreadsheet at g:\rgcwork\\Data_slide_update\data\source_data_analysis.xls Message: This complicated slide shows that since 1980 the total number of physicians, the number of actively practicing physicians, the number of physicians in non-primary care specialties, and the number of primary care physicians have all consistently increased more than the population has grown. The green triangles represent the primary care physicians, and even when the three primary care physician groups are combined, it is clear that other specialties continue to dominate growth in the physician workforce. Other Notes : Looking at U.S. Census data and the AMA Masterfile data…..IN THE YEAR 2000 THERE WERE ABT 275 MILLION PEOPLE IN THE U.S. AND ABT 813,000 DOCTORS. To make this more manageable to look at, I calculated the # of Docs there are/have been in the U.S. per 1,000 people. For active docs (blue) we see that in the year 2000 there were over 2.5 active docs per every 1,000 people in the U.S. But when people say they “went to a doctor’s office, they’re pretty much referring to OUTPATIENT PCPs. If you add the FP/GP, Ped, and GIM folks all together for the year 2000, you get 0.87 docs per 1,000 people. More information can be found at:: http://www.graham-center.org/PreBuilt/physician_workforce.pdf

Primary Care Shortage?Primary Care Shortage?

Currently a problem of distribution, Currently a problem of distribution, composition, and scopecomposition, and scope

Still concentrated in desirable areasStill concentrated in desirable areasRelative shortage in underserved and rural Relative shortage in underserved and rural areas, of certain demographics, and of a areas, of certain demographics, and of a complete, uniform basket of servicescomplete, uniform basket of servicesTrue for physicians, NPs and True for physicians, NPs and PAsPAs

Training Pipeline IssuesTraining Pipeline Issues

Market vs. Policy: Can Senate/House Market vs. Policy: Can Senate/House efforts to rebalance Graduate Medical efforts to rebalance Graduate Medical Education to favor primary care overcome Education to favor primary care overcome market realitiesmarket realities……School admission policies, debt, & primary School admission policies, debt, & primary care payment, workload, & prestige all care payment, workload, & prestige all weigh against entry into PCweigh against entry into PC

Status check: Family MedicineStatus check: Family MedicineFamily

Medicine Positions

March, 2008

Filled by US Graduates

Presenter

Presentation Notes

Even at its peak of popularity a decade ago, Family Medicine could not fill ¾ of its slots with graduates of US medical schools Since Congress put Medicare funding cap in place in 1996, the total number of residency positions has grown by 8% but FM has lost 639 slots -- 20% of its positions Primary care track GIM has fallen from

MedPAC June 2008

Student InterestStudent Interest

General Internal Medicine General Internal Medicine 2.0%2.0%Med/Med/PedsPeds 2.7%2.7%Family MedicineFamily Medicine 4.9%4.9%General PediatricsGeneral Pediatrics 11.7%11.7%

Total: Total: 21.3%21.3%

K. E. Hauer et al. Choices Regarding Internal Medicine Factors Associated With Medical Students' Career JAMA. 2008;300(10):1154-1164

Presenter

Presentation Notes

Karen E. Hauer; Steven J. Durning; Walter N. Kernan; et al. Choices Regarding Internal Medicine Factors Associated With Medical Students' Career JAMA. 2008;300(10):1154-1164

M. H. Ebell. Future Salary and US Residency Fill Rate RevisitedJAMA. 2008;300

Income Disparity affects Choice

True in 1989, true now

Is that a surprise?

Income Gap?

Presenter

Presentation Notes

Future Salary and US Residency Fill Rate Revisited Mark H. Ebell JAMA. 2008;300

R.O.A.D BuildingR.O.A.D Building

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 5000002007 Median Specialty Income

Perc

ent C

hang

e in

Num

ber o

f PY-

1 Av

aila

ble

r = 0.87Income change adjusted for

inflation 1998-2007

Reliance on International Medical Reliance on International Medical GraduatesGraduates

IM

Anesthesiology

Family Medicine

OBGYN

IM Sub-specialties

General Surgery

Pathology

Physical MedPsychiatry

Pediatrics

-1000

-500

0

500

1000

1500

2000

Source: JAMA Medical Education Issues, Ed Salsberg, AAMC

Change in Number of IMGs in Training 2002-2006

Decline in interest among US graduates

Growth of subspecialty positions

Training Pipeline IssuesTraining Pipeline Issues

Market vs. Policy: Can Senate/House Market vs. Policy: Can Senate/House efforts to rebalance Graduate Medical efforts to rebalance Graduate Medical Education to favor primary care overcome Education to favor primary care overcome market realitiesmarket realities……School admission policies, debt, & primary School admission policies, debt, & primary care payment, workload, & prestige all care payment, workload, & prestige all weigh against entry into PCweigh against entry into PC

But there is But there is evidence of evidence of

the the effectiveness effectiveness

of policy of policy across the across the

primary care primary care pipelinepipeline

PaymentPayment

Primary care is increasingly pushed away Primary care is increasingly pushed away from broad scopefrom broad scope

‘‘Nothing new under the sunNothing new under the sun’’ –– PCMH as Political ConstructPCMH as Political Construct

PCMHPCMH

Attitude and Cultural ChangesAttitude and Cultural Changes

Team based careTeam based careAsynchronous communicationAsynchronous communicationPopulation basedPopulation basedProactiveProactivePatient centeredPatient centered

Process & Structural ChangesProcess & Structural Changes

Open accessOpen accessEMREMRGroup visitsGroup visitsQI initiativesQI initiatives

31

• See also: Nutting, et.al. Annals of FamilyMedicine; Vol. 7, No. 3; May/June 2009

Policymakers & NumbersPolicymakers & Numbers

'A low voter turnout is an indication of fewer 'A low voter turnout is an indication of fewer people going to the polls'.people going to the polls'.

--George W Bush [George W Bush [FmrFmr. President USA] . President USA]

““Like elaborately plumed birdsLike elaborately plumed birds…… we preen and strut and display we preen and strut and display

our tour t--valuesvalues””

--Edward Edward LeamerLeamer, UCLA Economist, UCLA Economist

Presenter

Presentation Notes

ASSOCIATION VS CAUSATION – quote from Economist article Aug 15th, pg 68 “Cause and Defect”

Repacking Evidence for Delivery to Repacking Evidence for Delivery to Policymakers requires creativityPolicymakers requires creativity

……and thinking like a 3rd graderand thinking like a 3rd grader

Meeting in the middle: Meeting in the middle: HSR and the PolicymakerHSR and the Policymaker

OneOne--pagerspagers: Policy briefs anchored around : Policy briefs anchored around a single piece of evidencea single piece of evidenceRGC UpdateRGC Update: Annually updated, : Annually updated, annotated, referenced policy evidence annotated, referenced policy evidence summariessummariesFactsheetsFactsheets: State, School or Residency : State, School or Residency level level HealthLandscapeHealthLandscape: GIS engine for : GIS engine for the common manthe common man

Graham Center UpdateGraham Center Update

Reframing the GP for the policy Reframing the GP for the policy audienceaudience…… as Economic Stimulus?as Economic Stimulus?

Impact per Family Impact per Family Physician/year Physician/year

(average)(average)

$904,696$904,696

Range (state to state)Range (state to state) $660,392 $660,392 -- $1,259,838$1,259,838

Total Nationwide Total Nationwide Impact per yearImpact per year

$46,183,968,060$46,183,968,060

Presenter

Presentation Notes

Updated: Bazemore, 1.16.09 Source: IMPLAN dataset, Data Extraction & Analysis Robert Graham Center staff, 2006 Message: While most medical specialties tend to cluster in urban areas and near academic health centers, family physicians are the specialists most likely to work in areas with the greatest needs. In addition to the essential preventive and primary care foundation they provide for these communities, family physicians are significant generators of economic activity in local communities, having an average impact of $904,696 per doctor, per year on their communities, and over $46 billion nationwide. Notes:

……and considering novel or effective and considering novel or effective visual displayvisual display

Presenter

Presentation Notes

Probably the best statistical graphic ever drawn, this map by Charles Joseph Minard portrays the losses suffered by Napoleon's army in the Russian campaign of 1812. Beginning at the Polish-Russian border, the thick band shows the size of the army at each position. The path of Napoleon's retreat from Moscow in the bitterly cold winter is depicted by the dark lower band, which is tied to temperature and time scales.

The Power of Mapped DataThe Power of Mapped Data

Creating Data Layers . . . linking digital data to “geography”

Creating Data LayersCreating Data Layers . . . linking digital data to . . . linking digital data to ““geographygeography””

Street AddressesStreets/Rivers/Land FeaturesHospital/Medical Center/ ClinicsZip Codes/CountiesSpatial Analysis – (i.e.travel times)Service Demand/Provider Density

Street AddressesStreet AddressesStreets/Rivers/Land FeaturesStreets/Rivers/Land FeaturesHospital/Medical Center/ ClinicsHospital/Medical Center/ ClinicsZip Codes/CountiesZip Codes/CountiesSpatial Analysis Spatial Analysis –– (i.e.travel times)(i.e.travel times)Service Demand/Provider DensityService Demand/Provider Density

Physician to Population Ratios Physician to Population Ratios 19801980--20062006

(Physicians per 100,000 persons)(Physicians per 100,000 persons)

0

50

100

150

200

250

300

1980 1985 1991 1995 2000 2005 2006

Phys

icia

ns (M

D) p

er 1

00,0

00 p

erso

ns

All physicians Sub-Specialists Primary care physicians

Presenter

Presentation Notes

Updated: Dodoo – 3-20-2007 Data sources: 1. Number of physicians (MD only) 1980 to 1995 from http://bhpr.hrsa.gov/healthworkforce/reports/factbook02/FB202.htm 2. Relevant population numbers from U.S. Census Bureau, Statistical Abstract of the United States: 2006, Section I, http://www.census.gov/prod/2005pubs/06statab/pop.pdf, Tables 2 and 11 and from U.S. Census Bureau, Statistical Abstract of the United States: 2000, Section I, http://www.census.gov/prod/2001pubs/statab/sec01.pdf, Table No. 12 3 Number of physicians (MD and DO) 2000 and 2005 from AMA Master Files, SAS programs at g:\rgcwork\Data_slide_update\data\prg\summary1.sas 4. Number of osteopathic physicians 1980 - 1995 from American Osteopathic Association, Publications Division, AOA Fact Sheet, June 2000 http://www.osteopathic.org/pdf/ost_factsheet00.pdf - Calculations on doc_popln_ratios spreadsheet at g:\rgcwork\\Data_slide_update\data\source_data_analysis.xls Message: This complicated slide shows that since 1980 the total number of physicians, the number of actively practicing physicians, the number of physicians in non-primary care specialties, and the number of primary care physicians have all consistently increased more than the population has grown. The green triangles represent the primary care physicians, and even when the three primary care physician groups are combined, it is clear that other specialties continue to dominate growth in the physician workforce. Other Notes : Looking at U.S. Census data and the AMA Masterfile data…..IN THE YEAR 2000 THERE WERE ABT 275 MILLION PEOPLE IN THE U.S. AND ABT 813,000 DOCTORS. To make this more manageable to look at, I calculated the # of Docs there are/have been in the U.S. per 1,000 people. For active docs (blue) we see that in the year 2000 there were over 2.5 active docs per every 1,000 people in the U.S. But when people say they “went to a doctor’s office, they’re pretty much referring to OUTPATIENT PCPs. If you add the FP/GP, Ped, and GIM folks all together for the year 2000, you get 0.87 docs per 1,000 people. More information can be found at:: http://www.graham-center.org/PreBuilt/physician_workforce.pdf

Residency FootprintResidency Footprint

Virginia Commonwealth University Residency Graduates

Presenter

Presentation Notes

WHAT TIME PERIOD?

““FootprintingFootprinting”” Training Sites Training Sites –– Residency Residency & Medical School Social Accountability& Medical School Social Accountability

Localizing & Translating Complex Localizing & Translating Complex AnalysisAnalysis……

Customizing Data: Logical Next Customizing Data: Logical Next StepStep

WebWeb--based mapping toolsbased mapping toolsBridges Technology/Cost barriers for usersBridges Technology/Cost barriers for usersPuts Puts ‘‘dormantdormant’’ data (Provider data, HPSA, data (Provider data, HPSA, Census, Political Boundaries, etc.) in the Census, Political Boundaries, etc.) in the hands of grassroots primary care users and hands of grassroots primary care users and advocatesadvocatesResearch & Planning Applications: Expand Research & Planning Applications: Expand downstream as users multiply, data is pooleddownstream as users multiply, data is pooled

Putting primary care clinics on the Putting primary care clinics on the mapmap

Much policymaking and planning is localMuch policymaking and planning is localClinicians and regional planners think in Clinicians and regional planners think in context of community & geographycontext of community & geographyBut lack tools to understand But lack tools to understand

Gaps in access, service deliveryGaps in access, service deliveryImpacts of social determinants of health on Impacts of social determinants of health on clinical outcomesclinical outcomes

Understanding WHERE We ServeUnderstanding WHERE We ServeUnity Service Area (2007)Unity Service Area (2007)

(Service Area Threshold 70%)(Service Area Threshold 70%)N= 77,400N= 77,400

Unity Patients with AsthmaUnity Patients with Asthma-- Ages <17 years (2006)Ages <17 years (2006)

ICD9 used: 493ICD9 used: 493

Avoidable Hospitalizations Avoidable Hospitalizations Ages <17 years (2002)Ages <17 years (2002)

(DCPCA 2003)(DCPCA 2003)

Quality ImprovementQuality Improvement

Presenter

Presentation Notes

I think the frontier in using GIS for clinical applications is in developing QI initiatives. We see in the map on the left that avoidable hospitalizations for children are highest in the east and southeast quadrants of DC. We know from the data that the vast majority of these avoidable hospitalizations are due to asthma. In many neighborhoods of Southeast DC, Unity is the only health center available.

ConclusionsConclusions

U.S. Health Reform Train is speeding forwardU.S. Health Reform Train is speeding forward……Alongside a 1000 foot chasmAlongside a 1000 foot chasmOn a rusty & poorly maintained trackOn a rusty & poorly maintained trackPrimary & Preventive Care (not PHC) are Primary & Preventive Care (not PHC) are nominally central to Reformnominally central to ReformBarring derailment, weBarring derailment, we’’ll see real changes to PC ll see real changes to PC Access, Payment and InfrastructureAccess, Payment and InfrastructureBut not significant enoughBut not significant enough…… as in as in Massachusetts, Cost & QI will still demand Massachusetts, Cost & QI will still demand solutionssolutions

ConclusionsConclusions

We are as liable for the lack of evidence based We are as liable for the lack of evidence based policymaking as the policymakerspolicymaking as the policymakersCommunication of results demands creativity Communication of results demands creativity and thoughtful communicationand thoughtful communicationHealth Services & Outcomes vary regionally and Health Services & Outcomes vary regionally and even at the practice leveleven at the practice level…… and and Politics are localPolitics are localConsider spatial analytic tools and aspects of Consider spatial analytic tools and aspects of your work, andyour work, andBe back here at 2PM if you want to hear moreBe back here at 2PM if you want to hear more……

Documents

Visualizing Primary Care, Policy & Reform · Expenditures vs vs Primary Care Score UNITED STATES BEL AUS GER CAN FIN DK NTH SPA SWE UK FRA JAP $0 $500 $1,000 $1,500 …