U.S. healthcare costs in 2016 totaled $3.3 trillion, comprising 17.9% of our gross domestic product that year. These costs have been increasing for decades and far exceed how much other countries spend on healthcare. Increased costs have not led to better health outcomes. It is estimated that on average, U.S. hospital services cost 60% above average when compared to 12 other countries, including Italy, Australia, France, Sweden, Canada, Finland, Portugal, Israel, Slovenia, and Korea.
While it may be controversial to admit, I do not think there has been enough of an investment in preventive care in the U.S. Don’t get me wrong, it is exciting to develop new medications and medical devices, but efforts should also be made to help people before there is a need for such interventions. Granted, not all ailments can be prevented, but of those that can, we should work together as a society to decrease their prevalence.
Currently, most healthcare dollars are concentrated on a small group of patients. It is well known that healthcare costs can rise rapidly at the end of life for many people. However, not much attention is given to this “super-utilizers” group. The “super-utilizers” are patients with chronic illnesses that are in and out of the hospital frequently. We cannot ignore the impact of this patient population in the rising cost of healthcare. One study found that only 11% of patients in the highest care group were in the last year of life. Many of these patients in the highest care group are in fact the super-utilizers.
According to the Centers for Medicare & Medicaid Services, the breakdown of how U.S. healthcare dollars are spent is 32% hospitalizations, 20% physician and clinical services, 10% prescription drugs, and other services. As you can see, the majority of healthcare costs come from hospital costs. This suggests that more focus should be placed on keeping patients out of the hospital. In order to do this, there will need to be more Primary Care physicians available to see patients and increased access to care. We need to have reasonable charges for these visits and alternative ways to access physicians through phone calls and virtual visits as the costs of physicians visits have also been on the rise. (I will not delve into the intricacies of insurance and affordability of services as they are beyond the scope of this piece.)
Super-utilizers will continue to grow as people are living longer and with more co-morbidities and we will not be able to continue to ignore this very important patient population. The costs of emergency room visits and hospital stays on the healthcare system are high. If patients are being repeatedly hospitalized for chronic illnesses, we will be fighting a losing battle.
In the same study that found that this high utilization group makes up the majority of healthcare costs also showed it includes patients with complex co-morbidities. We need Primary Care physicians and specialists working together to help manage these chronic illnesses and keep these patients out of the hospital. We need to shift toward preventive care and health education for many patients. We need to support our Primary Care physicians and encourage our healthcare system to support them.
According to the American Board of Internal Medicine, in 2016 there were 7,761 third-year residents and the following year there were 5,044 first-year fellows. The data suggests a large proportion of Internal Medicine residents go on to pursue fellowships. While not all first-year fellows start directly after the third year of residency and these numbers likely overestimate the percentage going into fellowship, this is still the majority of Internal Medicine residents —and the numbers continue to rise. On a positive note, there has been an increase in Family Medicine residents with 3,535 medical students matching into Family Medicine this year.
Medical students will not be enticed to go into Primary Care if they are not compensated fairly or do not encounter mentors during their training. We need to praise all the work Primary Care physicians are doing on the frontlines because change may actually come from simplifying healthcare and not by adding more complexity.
Dr. Fola Babatunde is a Cardiology fellow at the Washington University School of Medicine in St. Louis. She graduated from Harvard Medical School and completed her residency at Duke University Medical Center.
Dr. Babatunde is a 2018–19 Doximity Author.