Philadelphia is a city of “firsts.” It is where colonists first declared independence from England. It was the first planned city in the New World. It is also the location of the first American hospital and medical school. I take special pride in having served the underserved communities of Philadelphia – a city to which American medicine owes so much – as a medical student at Temple.
During my recent time there, Temple Health was spending more than $100 million a year on charity care, much of it on an uninsured or underinsured population in a turbulent surrounding community. Many uninsured Philadelphians end up in Temple’s Emergency Department; in fact, applicants to the medical school and ER residency are lured by the prospect of seeing one penetration wound – that is, a gunshot injury or stabbing – per day. Dr. Amy Goldberg leads a robust program caring for trauma patients, and is one of the most brilliant educators that I encountered while at Temple.
While caring for that population and spending $100 million annually to do it is a noble cause, I don’t look at that as a statistic to be especially proud of.
From a business perspective, any health system that gives away that much free care is shooting itself in the foot. More importantly, from a patient care perspective, that number shows that our health care system is failing in its medical duties, no matter how good we are at robotic surgery, trauma care or research.
The United States spends 17.9 percent of its yearly gross domestic product on health care, far more than the second-most developed country – the Netherlands – spends per year. However, according to the most recent numbers from the Centers for Disease Control and Prevention, the U.S. ranks 30th in infant mortality, one of the World Health Organization’s primary indicators of health.
How can Temple and other communities in the United States avoid growing debt from health care spending while actually improving the health of the populations they serve? In my opinion, giving that population a relationship with a primary care physician is the answer.
Insurance companies are increasingly realizing the cost-savings and quality that primary care physicians bring to a health care system, especially through the Patient-Centered Medical Home model of care, which advocates for comprehensive, coordinated and accessible primary care for patients and their families.
According to the nonprofit Patient Centered Primary Care Collaborative, a collective of insurance companies, employers, doctors, nurses and patients, some of the benefits of patient-centered care include lower costs of care, improved outcomes for conditions like cancer and heart disease, improved life expectancy, decreased mortality rate and reduced impact of socioeconomic disparities.
Family physicians also decrease the mortality rate more than other primary care physicians. Why? As a family physician now working in a PCMH in Billings, Mont., a city with remarkably similar problems to Philadelphia, I have realized firsthand what a family physician provides: a window into the major health determinants in the families and community that I serve.
For example, I recently saw a child brought in for care by his depressed mother whose husband was battling alcoholism, and who was also struggling to care for her diabetic mother. While these relatives may never have seen a physician otherwise, at this same visit I can treat what might be the most important factor in the child’s health: his family. More importantly, working in a PCMH, I can refer this family to in-house services including behavioral health for the mother, home health for the grandmother and substance dependence treatment for the father.
If Temple and other academic health systems in Philadelphia and the U.S. want to improve outcomes while reducing astronomical spending on emergency and charity care, let them serve as role models to other health systems and prevent those costs by investing in the PCMH model.
This transition can start with medical schools and their affiliated health systems acknowledging that approximately 90 percent of graduates going into internal medicine and 40 percent of graduates going into pediatrics will eventually specialize. They must also recruit more family physician faculty, increase the number of family physicians in their administrations, invest in partnerships with local community health centers to provide students and patients the opportunity to experience effective primary care and lobby at the national level for payment reforms to increase valuation for primary care services.
Targeted investment in primary care is a long-term strategy to combat the continued rise of costs and to improve wellness. Just maybe, with a sustained investment in preventive and primary care, we will eventually see charity care costs and bullet wound numbers decrease. No hard feelings to Dr. Goldberg, but I’m hopeful that we can decrease the need for doctors in her profession in the coming decades if we appropriately prioritize medical education
If Philadelphia medical schools are to “create the next generation of health care leaders,” let them look toward primary care. Philadelphia has been at the forefront of medicine in the United States in the past, and it can be again if its academic medical centers lead the way by investigating in-patient centered primary care.
Christopher Baumert, MD; Family Medicine Resident Physician and 2011 Graduate of Temple University School of Medicine.