Rhode Islanders currently spend at least $5.8 billion on health care for individuals each year. Our state government shoulders between $1.7 billion and $2.1 billion of that health care burden between state employee benefits and Medicaid. While we argue about how many hospitals we should have, and who gets to run them, the costs go up, and the health we measure – infant mortality, life expectancy and cancer mortality – lags that in places that spend far less.
Other states, and other countries, do better by increasing the number of primary-care physicians per 10,000 people, and by making primary-care practices more robust. Imagine what Rhode Island would be like if we had a primary-care practice with six doctors, three nurses, two physical therapists, three mental-health workers, two dentists, and three visiting nurses in every community? A primary-care practice that would be open from 9 a.m. to 9 p.m. and on weekends? One place, where the entire community can go for 90 percent of its health-care needs.
Believe it or not, such a system is affordable now. We are already spending the money such a system costs on the services such a system delivers – but we are spending that money in a disorganized way, and we are not seeing the benefits of organizing – and leveraging – the affordable price and incredible value of primary care.
The truth is that primary care has a public purpose, a value too precious to be abandoned to catch-as-catch-can development of doctors coming out of residency, and hospitals seeking to boost their market share.
Primary-care trusts are used in the United Kingdom to organize its health care system, which delivers high-value care in a way that costs about half of what we have here. We can learn from the British and use a primary-care trust in Rhode Island to help develop a primary-care health care system to serve all Rhode Islanders.
A primary-care trust would support the development and distribution of primary-care practices in Rhode Island by assisting practices in the process of business development, financing and location. Practices could grow to the size at which they can offer the services we need them to offer in the places we need them to be, and remain profitable as they grow. The trust would facilitate medical school loan repayment, so that young primary-care doctors could practice in Rhode Island, despite student loan debt nearing $200,000. In addition, the trust would measure and track the quality of Rhode Island primary-care practices, and track the impact of our practices on the communities they serve. In addition, the trust would provide a home for primary-care, residency-training programs, and would be able to raise charitable funds in support of the primary-care process, which is critical to the public’s health.
There are a number of ways of financing such a trust, ranging from levying a small assessment on all insurance transactions to asking for public support. And it is true that many details, including governance and oversight, funding and their role in state health policy, need to be worked out.
But surely the time for a public role in developing a primary-care system – as the foundation for an affordable, fair and rational health care system – is here. We would all be wise to recognize the opportunity that a primary-care trust provides, and work together to build what has always eluded us but what we so desperately need – a health care system for all. •
Dr. Michael Fine is a family physician practicing in Scituate and Pawtucket and is the facilitator of the Primary Care Leadership Council, which represents 75 percent of Rhode Island’s primary care practices and community health centers.
Dr. Fine is also the author of an excellent new book on the topic and a thought leader in the healthcare reform movement. There is little doubt his concept of a patient centered delivery system has merit, but we will need to reform the present reimbursement system to enable the change.