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Center for Policy Studies
Public Affairs Discussion Group |
| Loving Primary Care to Death? More Ironies of “Health Care Reform” |
Joe White, Ph.D. - Luxenberg Family Professor of Public Policy |
Kurt Stange, MD, Ph.D. - Distinguished University Professor and Dorothy Jones Weatherhead Professor of Medicine |
Friday April 25, 2025
12:30-1:30 p.m.
Meeting Both In-Person and by Zoom
Alternate Room: Mather House 100, 11201 Euclid Ave
Case Western Reserve University
For those interested in participating by Zoom please e-mail padg@case.edu for more information.
Dear Colleagues:
Our final “Friday Lunch” of the 2024-25 academic year will address one of the seemingly permanent themes in the health policy literature.
That is the idea that the United States’ medical care system has devalued primary care, given disproportionate attention and resources to more specialized care, and that this is one important reason why American health care costs so much more per capita than in other countries, but health outcomes are significantly worse. Our system, more than others, is said (with some reason) to be divided into siloes that treat body parts more than whole people, may work at cross-purposes on people with multiple conditions, and leaves patients with the impossible task of coordinating their own care. Siloes are contrasted to the “four C’s” of primary care defined by Barbara Starfield: accessibility for first Contact when a person feels ill, Coordination, Comprehensiveness, and Continuity. As Kurt Stange has explained, this vision has inspired generations of reformers.
The concern seems in some ways self-evidently true. In different countries the medical disciplines are divided somewhat differently, and so using the most common labels will understate the share of “primary care” physicians in the United States, by leaving out categories such as general internists and pediatricians whose work mostly fits the bill. Nevertheless, a wide range of studies finds that the ratio of specialists and so specialist work to primary care providers and their work is unusually high in the United States. And this is clearly related, among other things, to the latter work being devalued in the most basic way: how much doctors are paid. As a recent report from the National Center for Health Workforce Analysis put it, “the substantial gap in compensation between primary care physicians and specialist physicians may be one of the explanatory factors for medical students choosing residencies in specialties other than primary care.”
Nevertheless in spite of the discussion of the problem for many decades, it doesn’t seem to be getting any better. It may well be getting worse, as the Milbank Memorial Fund declared in a recent report subtitled, “No One Can See You Now.” As the National Center for Health Workforce Analysis put it, “it is well-documented that significant challenges face the workforce providing this care. These include shortages and maldistribution of primary care providers (PCPs), low compensation compared to other health occupations, increasing burnout and job dissatisfaction, and an aging workforce.”
It seems to me, however, that the problem is not simply a failure to increase compensation. Instead, policy-makers claiming to recognize the importance of primary care have made it worse with well-meaning but mistaken reforms, or half-baked attempts to find cheap solutions.
In the first category, a wide range of reforms such as quality measures in electronic medical records have made the jobs of primary care doctors much more difficult. Policies that seek to ensure coordination by requiring that patients be referred to specialists by their PCP in many cases create extra work for not enough reason. Policies that seek to get PCP’s to take account of things they cannot affect, such as the social determinants of a patient’s health, both add work and set up doctors for failure. In short, “burnout and job dissatisfaction” are in part created by policies that were supposed to prioritize and improve primary care.
In the second category, there is a continual campaign to replace the “cottage industry” of solo or small-group primary care with larger “teams” of nurses and other auxiliary care givers. In particular in the United States, the “workforce” increasingly consists of more Physician Assistants and Nurse Practitioners compared to physicians. There are ways that this can be helpful, but it can also create new costs, make the job of a doctor more that of a manager, reduce continuity of care and the personal relationships that make care more caring, and in general make care more bureaucratic in the negative connotations of the word.
So I am not sure, but my suspicion is that, on balance, much of the practice transformation that has been meant to promote and encourage primary care has instead made being a primary care doctor a worse experience. And job. Pay relative to specialists may have slightly improved over the past decade or so. At least at some times. But the relative workload and hassles probably have increased more. To put this another way, expressing the importance of primary care by loading more tasks on it seems more likely to kill it than help it.
I will explain my fears in this final “Friday Lunch” of the semester. They are based on my sense of both the difficulties of organizing medical care and trends around the advanced industrial world. I hope people who participate will find my argument interesting. But I’m also doing this because I greatly look forward to hearing Kurt Stange’s response. The longtime editor of the Annals of Family Medicine, our colleague Professor Stange is simply one of the nation’s leading scholars of primary care, its practice and its challenges. I know he too is worried about trends; we’ll see how much we share a diagnosis of the difficulties and prospects.
Thanks and…
As mentioned above, this is the final “Friday Lunch” of the Spring and the 2024-2025 academic year. I am returning both as speaker and moderator, a short interim in my sabbatical. Many, many thanks to Professor Parris for leading the discussions for most of the semester, and to Professor Ledford for moderating our lively discussion last week. Thank you also to Meg Coyle, our student assistant who has done a spectacular job of keeping things running. Thank you to Dr. Andrew Lucker for his many years of managing this newsletter and helping out in other ways. And of course many, many thanks to the Kelvin Smith Library administration and staff who have enabled us to make the Dampeer Room our usual home.
Absent unpleasant surprises, we should reconvene again on Friday, August 29, at the usual 12:30 pm. If you have ideas about potential speakers or topics (preferably both together), please send them to me at joseph.white@case.edu.
For the final gathering of the year, as I will be back in time, my wife Sydelle and I will bake the goodies for the in-person group. No cake, though I hope the cakes were a good replacement.
This has been a rough year in many ways; I hope it gets better at least for most. Eventually.
Best wishes for safety and security for you and yours,
Joe White
Luxenberg Family Professor of Public Policy and Director, Center for Policy Studies
About Our Guests
Joe White is organizer of the Public Affairs Discussion Group due to his position as Director of the Center for Policy Studies in CWRU’s College of Arts and Sciences. He holds the Luxenberg Family Professorship in Public Policy with his primary appointment in the Department of Political Science and a secondary appointment in the Department of Population and Quantitative Health Sciences.
Dr. White joined our faculty in 2000 and served as Political Science Department Chair from 2003 – 2015. Before coming to CWRU he was an Associate Professor of Health Systems Management at Tulane University, and first Research Associate and then Senior Fellow in the Governmental Studies Program of the Brookings Institution. He earned his A.B. from the University of Chicago and his M.A. and Ph.D. from the University of California Berkeley, all in political science.
Dr. White’s research focuses especially on both U.S. federal budgeting and health care policy and politics. A lot of his health policy work compares policies across rich democracies. He has authored or co-authored three books, co-edited two, and authored or co-authored 85 articles or book chapters. These include his book with Aaron Wildavsky on budgeting during the Reagan administration, and nine other articles or chapters about presidents and budgeting. His c.v. and a selection of his work can be found at https://policy.case.edu/research/health-care-federal-budget-articles/.
Kurt C. Stange is a family and public health physician. At Case Western Reserve University he is a member of the Center for Community Health Integration (CHI Center), which conducts collaborative Research & Development for Community Health and Integrated, Personalized Care. He is a Distinguished University Professor, and is the Dorothy Jones Weatherhead Professor of Medicine, and Professor of Family Medicine & Community Health, Population & Quantitative Health Sciences, Oncology and Sociology. With Rebecca Etz, Ph.D., he serves as Co-Director for the Larry A. Green Center for Advancing Primary Health Care for the Public Good. He is interested in how the generalist function and the personal physician make a difference in people’s lives. He is a member of the Academy of Medicine of the US National Academy of Sciences. | |
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