Cost Effective Care

The physician who is well acquainted with the patient provides more personal and humane medical care, and does so more economically, than the physician involved in only episodic care. The physician who knows his or her patients well can assess the nature of their problems more rapidly and accurately. Because of the intimate, ongoing relationship, the family physician is under less pressure to exclude diagnostic possibilities using expensive laboratory and radiologic procedures than the physician unfamiliar with the patient.

The United States has the most expensive health care system in the world. In 1965 the cost of health care in the United States was just under 6% of the gross domestic product (GDP). It shot up to 16% of GDP in 2008 and continues to increase, with predictions it will reach 20% by 2015. Despite the most expensive health care, however, the United States ranks 29th in infant mortality, 48th in life expectancy, and 19th (of 19) in preventable deaths among industrialized nations. *

Although the rhetoric suggests it is worth this cost to have the best health care system in the world, the truth is that we are far from that goal. WHO ranks the quality of health care in the United States at 37 th in the world, well behind Morocco and Colombia. (For the standing of all countries see www.photius.com/rankings/health ranks.html.) In a comparison of the quality of health care in 13 developed countries using 16 different health indicators, the United States ranked 12th, second from the bottom. Evidence indicates that quality of health care is associated with primary care performance. Of the seven countries at the top of the average health ranking, five have strong primary care infrastructures. As Starfield (2000) states, "The higher the primary care physician-to-population ratio, the better most health outcomes are" (p. 485).

Similarly, the greater the number of primary care physicians practicing in a country, the lower is the cost of health care. Figure 1-3 shows that in the United Kingdom, Canada, and the United States, the cost of health care is inversely proportional to the percentage of generalists practicing in that country. Great Britain has twice the percentage of family physicians but half the cost. Administrative overhead accounts

*www.aafp.org/online/news-now/professional-issues/20081223health-ceos.html. Accessed January 2010.

Figure 1-3 Inverse relationship between number of generalists and cost of health care in the United Kingdom, Canada, and the United States. (From Organisation for Economic Cooperation and Development. OECD Health Data, June 2005. http://www.oecd.org/document/56/0,2340,en_2649_34631_12968734_1_1

1_1,00.html/ Accessed April 2006.)

Figure 1-3 Inverse relationship between number of generalists and cost of health care in the United Kingdom, Canada, and the United States. (From Organisation for Economic Cooperation and Development. OECD Health Data, June 2005. http://www.oecd.org/document/56/0,2340,en_2649_34631_12968734_1_1

1_1,00.html/ Accessed April 2006.)

for a major part of the high overhead cost (31%) of U.S. health care (Woolhandler et al., 2003). For the same number of physicians, Canada has one "billing clerk" for every 17 in the United States (Lundberg, 2002).

Countries with strong primary care have lower overall health care costs, improved health outcomes, and healthier populations (Starfield, 2001; Phillips and Starfield, 2004). In comparing 11 features of primary care in 11 Western countries, the United States ranked lowest in terms of primary care ranking and highest in per-capita health care expenditures. The United States also performed poorly on public satisfaction, health indicators, and the use of medication (Starfield, 1994).

In the United States, the greater the number of primary care physicians, the lower is the mortality, and conversely, the higher the specialist/population ratio, the greater is the mortality. Adding one family physician per 10,000 people would result in 35 fewer deaths. Increasing the number of specialists, a process that continues in the United States, is associated with higher mortality and increasing cost. One third of the excessive cost is attributed to performance of unnecessary procedures (Starfield et al., 2005).

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