Better is still possible: Promoting improved health for all

We need the courage to fix the structural and fiscal inefficiencies that result in the United States having the highest health care costs and the worst outcomes among developed countries.

Two weeks ago, I was invited to participate in a panel at the Binaytara Foundation's Summit on Cancer Health Disparities and was struck by how disparities in outcomes for cancer patients mirrored disparities seen throughout our health care system. Despite the United States' outsized expenditure on cancer treatment and other forms of health care, we continue to rank at or near the bottom of the list of developed countries in health care outcomes, life expectancy, patient satisfaction, and community wellness indices.

Countries such as Sweden, Germany, Switzerland, and Japan have much more integrated health care systems and much fewer disparities and better outcomes than we do. The fact that these comparator countries can and do provide better health care for their people is a clear illustration that better is possible. How to get there is the challenge.

The American College of Physicians sees health as a human right and considers access to high-quality, patient-centered, accessible, and equitable care for all persons as the cornerstone of a functional health care system. As a moral society, this must also be at a cost that individuals and our society can afford. In January 2020, the College published a series of policy papers envisioning a better U.S. health care system that included recommendations for improved health care delivery and payment systems reform. Four years later, we still believe that better is possible. All we need is the courage to fix the structural and fiscal inefficiencies that result in the United States having the highest health care costs and the worst outcomes among developed countries.

Our system (or lack thereof) struggles with a multifaceted set of problems, deeply entrenched through a complex interplay of political, social, economic, and structural factors, including disparities in access, insurance coverage, quality outcomes, social determinants, and structural racism and bias. To address these problems, we need a comprehensive approach that tackles the root causes and includes but is not limited to policies that expand health care coverage, develop a functionally integrated health care infrastructure, address poverty and health literacy, address bias in health care, and address the distribution and availability of the health care workforce.

This last element is at the core of one of ACP's new strategic priorities recently approved by the Board of Regents: addressing the changing dynamics of the internal medicine workforce. Based on 2021 data, the Association of American Medical Colleges' 2022 Physician Data Specialty Report indicates that internal medicine physicians account for the largest number of doctors in the primary care specialties (120,342), followed by family medicine (118,641) and pediatrics (60,305). However, there has been a steady decline in internal medicine residency graduates choosing to pursue general internal medicine and primary care, opting instead for hospital medicine or subspecialty practice. Addressing the changing dynamics of the internal medicine workforce and encouraging new residency graduates to pursue general internal medicine are pivotal to maintaining a sturdy foundation of primary care, which in turn helps address the inequitable access to high-quality, patient-centered care that plagues our system.

Given the current practice dynamics and reimbursement and administrative burdens, primary care seems an unattractive option for many young physicians. Low reimbursement rates for primary care services, undervaluation of cognitive work as compared to procedures, crushing administrative burdens that add no value to patient outcomes, constricting rules and regulations that limit innovation, and a pervasive sense of disrespect from other physicians and the public remain huge detractors from pursuing primary care practice. We will need to address these factors to make any meaningful progress in shoring up this vital component of our health care infrastructure.

The College's prioritization of the internal medicine workforce as a strategic priority is therefore timely and appropriate. Finding solutions to the challenges listed above will take a lot of time and hard work, but I believe a commitment by our entire membership to critically examine the problems, suggest and find solutions, and speak truth to power when necessary will take us much closer to the goal of "better is possible": better outcomes for our patients and improved professional satisfaction for our colleagues.

In addition to addressing the workforce problems in primary care, we must also collaborate with partners and stakeholders to address other challenges that make it difficult to provide high-quality, patient-centered, and equitable care. We must address the regulatory frameworks that affect how we practice, from fee-for-service reimbursement to administrative burdens that put paperwork before patients. We must reform our payment system to ensure that the cognitive skills needed to care for complex patients with multisystem illnesses are appropriately valued and reimbursed and enable physicians to innovate and develop patient-centered treatment plans as they deem appropriate to achieve the best outcomes for their patients.

We must also advocate for innovative care models that place the physician at the heart of health care teams designed to enable each professional member of the team to practice at the top of their clinical ability while promoting patient outcomes and minimizing harm. Many proposed "independent practice" models, while anecdotally improving access to care, do not provide for the coordinated and skilled care essential for many patients with multisystem illnesses. Internal medicine physicians, the "experts in complexity," are uniquely suited to lead these teams and must be part of any conversation aiming to redesign care and reimbursement models.

As we aspire to catch up and surpass other developed countries in health outcomes and community satisfaction and wellness, we must address social, economic, and structural factors that go beyond the physician workforce. We must improve access to care for all persons through structural changes such as establishment of community-based primary care clinics; coverage reform to include immigrants and other marginalized populations; emphasis on and cost reduction of preventive services such as screening, vaccination, and chronic disease management; and promotion of healthy living, including substance misuse prevention and treatment.

Our College came together four years ago and proposed a bold initiative: Better is possible. It is now our chance to make this vision a reality. We have the strength and skills to push forward many of these proposals from within the house of medicine. As I mentioned during my remarks at Internal Medicine Meeting 2024, the beginning of my term as President, we see the patients, develop and evaluate the interventions, set the standards, and provide care with professionalism and compassion. We should be innovative in our approach to these challenges, harnessing technology, proposing changes and sundowning of administrative tasks, and improving the overall health care experience for our patients while rekindling the joy of practice for ourselves and our colleagues. Let the house of medicine come together to realize this vision.