**3. Negative system changes as obstacles to primary care**

Other advanced countries around the world ensure universal access to health care with a stronger role of primary care. The U. S. has evolved a profit-driven medical-industrial complex with deregulated markets and little oversight and

accountability by government. Much of U. S. health care has been corporatized, with a shift to for-profit health care, increased privatization, and growth of investor-owned corporate health care. These changes have resulted in:


These changes have worked against the further development of family practice. Private equity firms have driven purchases of many physician-owned medical practices, driving many to become hospital-affiliated employees [5]. Almost two-thirds of U. S. physicians are now employed by others, especially by large hospital systems, where they are under pressure to maximize revenues for their employers. This is a far cry from a generation ago when family physicians ran their own practices, rounded in the hospital, and worked in the community [6]. Not surprisingly, small group practice has almost disappeared, while practice satisfaction has declined for many physicians together with increasing burnout rates [7].

Other generational changes have been taking place over the past 30 years which change the landscape for traditional primary care. One of these is the increasing numbers of millennials who do not want a family doctor, but instead value the convenience of dropping in to an urgent-care facility with an acute need without any continuity or comprehensiveness of ongoing care. National polls have found that up to one-third of millennials take this approach [8]. That change is further enabled by the increasing wait times for those who want to visit a family physician, which has gone up to almost a month because of their shortage [9].

Primary care physicians in practice are besieged by electronic health records, which have become billing instruments, and having to spend an average of \$99,000 a year per physician for their billing activities that take away many hours from patient care [10]. They have to spend additional time in dealing with the different and changing policies of more than 1,000 private insurers over such everyday issues as restricted networks, drug formularies, pre-authorizations, and other requirements related to reimbursement.

The mantra of our unfettered marketplace holds that competition will bring efficiency and contain costs. That claim, however, has been proven false for years. As one example, the non-profit U. S. Center for Studying Health System Change conducted a nine-year study of 12 major health care markets in its Community Tracking Study involving 60 communities, 60,000 households and 12,000 physicians. It found four major barriers to efficiency: (1) providers' market power, (2) absence of potentially efficient provider systems, (3) employers' inability to push the system toward efficiency and quality; and (4) insufficient health plan competition [11].

The U. S. compares poorly among 11 countries periodically measured by the Commonwealth Fund, as illustrated by cost barriers for high-need older adults (**Figure 1**). Despite spending more for health care than any other country in the world (about \$1.3 trillion a year), the U. S. lags behind other countries in terms of mortality amenable to health care [12].

#### **Figure 1.**

*High-need older adults experience greater cost barriers to receiving care.*
