1. Health Care of the Future in the United States: The Imperative of Primary Care Jerry Kruse, MD, MSPH

2. Slides with commentary in green boxes No. 2-37 “Clean Slides” for power point presentations are Nos. 39-72

3. Ratio of Full-Time Equivalent Workers to Medicare Beneficiaries From 1970 to 2000, there was a manageable 15% decline in FTE Workers per Medicare Beneficiary (4.6 to 4.0). From 2000 to 2030, there will be a 40% drop, with a potentially catastrophic fall of 22% in the 10 year period 2010 to 2020. Medicare, as we know it, will no longer be viable

4. In 2002, the US infant mortality rate rose for the first time in 40 years. The US infant mortality rate now exceeds that of Cuba and Costa Rica, and is twice the rate of Singapore The Infant Mortality Rate in the United States Lags Behind Other Industrialized Nations and the Gap is Widening The US infant mortality rate has not improved since 2000, while the rest of the world has made substantial gains. Data analysis reveals that this is not due to multiple pregnancies or delayed childbearing. The likely cause is worsening access to care, a symptom of a system that has de-emphasized primary care, preventive medicine, and public health

5. Percentage of Women ages 18 to 65 who had a Pap Test within the past 3 years (1987-2003) Source: CDC, National Center for Health Statistics, National Health Interview Survey Age Adjusted using the NCHS 2000 Standard Population From 1986 to 2000, there was a steady increase in the percentage of women who had cervical cancer screening. Since 2000, there has been a linear, statistically significant decline in such screening that is likely a result of a de-emphasis of primary care, preventive medicine, and public health and policies that worsen access to health care.

6. Percentage of Women age 40 or over who had Mammography within the past 2 years (1987-2003) Source: CDC, National Center for Health Statistics, National Health Interview Survey - Age Adjusted using the NCHS 2000 Standard Population From 1986 to 2000, there was a dramatic increase in breast caner screening. Since 2000, there has been a linear, statistically significant decline in such screening that is likely a result of a de-emphasis of primary care, preventive medicine, and public health and the introduction of policies that worsen access to health care.

7. Comprehensive Review of the Effectiveness of Primary Care Contribution of Primary Care to Health Systems and Health Barbara Starfield, Leiyu Shi and James Macinko Johns Hopkins University, New York University The Milbank Quarterly, Volume 83, No. 3, 2005 Pages 457 - 502 This article is an excellent, comprehensive review of the effect of family medicine, generalist medicine, primary care, the personal medical home and characteristics of health systems upon health care outcomes and quality of care indicators. The rest of the slides rely upon data from the studies cited in this article and emphasize a set of studies by Starfield’s group at the Johns Hopkins Bloomberg School of Public Health and Baicker’s group at the Dartmouth Center for Evaluative Clinical Science

8. Population-Based Health Outcomes In the modern, industrialized world, the nations and regions that place a relatively greater emphasis on generalist medicine and primary care have consistently better health outcomes. Every population based study done since 1980 has had this finding, regardless of the population unit of care (nation, state, province, region or census tract), and regardless of the type of outcomes studied (i.e., primary clinical outcomes like death rates, quality of life, etc. or surrogate markers of quality, like screening rates, appropriate meds, etc.

9. Family Medicine and Generalist Medicine: The Physician Workforce The emphasis that a nation or a region places on public health and preventive medicine is reflected by: –The percentage of the total health care budget spent on public health –The percentage of the total physician workforce that are primary care (generalist) physicians The US ranks near the bottom in proportion of health care spending used for public health (40% vs. an average of about 70%-www.eriposte.com/health/other/healthcare_US.htm). The next slide summarizes this data. The US also ranks near the bottom in the percentage of physician workforce that are generalist physicians.

10. www.eriposte.com/health/other/healthcare_US.htm http://www.oecd.org/dataoecd/59/49/35529832.xls Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, UK, US USA 23 Other Nations

11. Institute of Medicine Definition of Primary Care “… (1) the provision of integrated, accessible health care services (2) by clinicians who are accountable for addressing a large majority of health care needs, (3) developing sustained partnerships with patients, and (4) practicing within the context of the family and community…” Donaldson, IOM Report, Primary Care: America’s Health in a New Era, 1996 IOM Report, 1978 General Pediatrics: The Medical Home Family Medicine: The Personal Medical Home General Internal Medicine: The Advanced Medical Home This is the definition of primary care that has been utilized in virtually all of the studies referred to in the Starfield article in the Milbank Quarterly. In the US, General Pediatrics, General Internal Medicine, and Family Medicine fulfill this definition. In the rest of the nations of the world, the primary care physicians that meet this definition are almost all family physicians or general practitioners.

12. Improving Health Outcomes for Populations Primary Care prevents illness and death through the following four mechanisms: 1. Supply of primary care physicians: Ratio of generalist physicians to the total population 2. Supply of primary care physicians: Ratio of generalist physicians to all physicians 3. Relationship with a source of primary care 4. Important features of the Health Care System Peds: Medical Home FP: Personal Medical Home GIM: Advanced Medical Home These general categories explain the power of primary care in lengthening life, decreasing disability and improving health. Each will be examined in the subsequent slides. The ratio of generalist physicians to all physicians is important because it reflects the emphasis that a nation places on primary care, preventive medicine, and public health.

13. Health Outcomes and the Supply of Primary Care Physicians: US Studies States with higher ratios of Primary Care Physicians to population had significantly better health outcomes, including: a. Lower rates of All-cause mortality b. Lower rates of Heart Disease mortality c. Lower rates of Cancer Disease mortality d. Lower rates of Stroke mortality e. Lower rates of Infant mortality f. Lower rates of Low Birth Weight infants g. Better Self-Reported Health h. Longer Life Span Shi. Journal of Health Services, 1994:24:431-458 Vogel, et al. International Journal of Health, 1998:28:183-196 The studies controlled for sociodemograhic factors: %elderly, urban, minority, education, income, unemployment, pollution, smoking

14. PCP Supply and Health Outcomes: Summary of United States Studies There is a consistent relationship between more primary care physicians and improved health outcomes, regardless of: Year of study (1980-2000) Lag period (Length of effect) Level of Analysis (State, County or Local) Type of Outcome Shi. Journal of Health Services, 1994:24:431-458 Vogel, et al. International Journal of Health, 1998:28:183-196 In summary, an increase of one primary care physician per 10,000 people (12.6%  ) is associated with a 5.3% decline in all-cause mortality (34 per 100,000 per year). Ten more primary care physicians in a region of 100,000 saves 34 lives each year. If the supply of primary care physicians were increased by 40% (see the Dartmouth data that follows), then 107 lives per 100,000 people would be saved each year, a total of over 300,000 annually in the US, far more than the IOM estimates of 90,000 unnecessary deaths annually in hospitals due to medical errors

15. The Effect of Physician Workforce on Health Outcomes Johns Hopkins Bloomberg School of Public Health: Six population-based studies of US, Canada, and Europe found that optimal primary health outcomes occur when 40-50% of the physician workforce are generalist physicians Dartmouth Center for Evaluative Clinical Science: Three studies using US nation-wide Medicare data bases found that quality health indicators are better and cost of care decreases as the number of generalist physicians increases. These two sets of studies form the solid foundation for the importance of the ratio of primary care physicians to the total physician workforce (Hopkins), and the ratio of primary care physicians to the population (Dartmouth). The outcome measures for the Hopkins studies were mostly measures of primary health outcomes, defined below, and those for the Dartmouth studies were measures of quality health indicators that are strong markers for primary health outcomes

16. Johns Hopkins Studies: Summary Primary health outcome measures – e.g., life expectancy, death rate, infant mortality rate, death rates from cancer and heart disease, etc.— are optimized when 40 to 50 % of the physician workforce is made up of generalist physicians Starfield B: British Journal of General Practice, April 2001, p303 Shi L et al: Journal of Family Practice, April 1999, p275 Starfield B: Health Affairs, March 15, 2005, p97

17. This is a theoretical mathematical model derived from the empirical data of the population based studies done at Hopkins. Currently, about 32% of US physicians are generalists, and for the past two match years (2005 and 2006), only about 18% of physicians entering residency are expected to choose careers as generalists

18. Primary Care Orientation: Practice and Health System Characteristics Nations, Counties and States with stronger primary care practices (personal medical homes) and certain health system characteristics have consistently better health outcomes, including: Lower all-cause mortality Lower neonatal mortality Lower cause specific mortality (Pulmonary Disease, Heart Disease, Cancer) Starfield. JAMA, 1991;266:2268-71 Starfield. Lancet, 1994:344:1129-34 Starfield, et al. Oxford University Press, 1998 Or. Health Care Mortality Across OECD Countries, 2001 Shi, et al. Health Services Research, 2002;37:529-550 Macinko, et al. Health Services Research, 2003;38:831-865

19. Practice Characteristics Associated With Improved Health Outcomes First Contact Care Patient-focused Care over time Comprehensive Care (Degree to which the primary care physician provides a broad range of health services) Coordinated Care Family Orientation (Degree to which medical services are provided to family member by the same provider) Community Orientation Cultural Competence 1. The Patient-Centered Medical Home Starfield & Shi: Pediatrics, 2004;113:1493-99 The references for these findings are on the previous slide. From an evidence based perspective, these are the elements that define the effective personal medical home. These elements are powerful tools that, by themselves, lead to dramatically improved health outcomes

20. The Patient-Centered Medical Home Legislative Definition of AAFP, ACP, AAP & AOA Personal Physician Physician Directed Medical Practice Whole Person Orientation Coordinated and Integrated Care Quality and Safety Measures Evident EBM and Clinical Decision Support Voluntary CQI Patient’s Expectation Met HIT used appropriately Voluntary Recognition Process Enhanced Access Appropriate Payment

21. Health System and Policy Characteristics Associated With Improved Health Outcomes 1.Attempts to distribute health services equitably with respect to regional health care needs 2.Universal or near-universal financial assistance guaranteed by a publicly accountable body 3.Low or no co-pay for health services 4.Percentage of physicians who are generalists 5.Similar professional earnings of primary care physicians relative to other specialties The US health system does not exhibit any of these 5 characteristics. (1) There is no cohesive plan to equitably distribute services. (2) No publicly accountable body guarantees coverage-now 46 million uninsured, and increase of 12% in 4 yrs. (3) Sen. Barack Obama reports that co-pays and deductibles have increased 50% and family premiums 65% in 4 yrs. (SIU School of Medicine graduation address May 20, 2006) (4) See the previous slides. (5) Disparity of income among physicians in the US is the highest in the world.

22. Primary Care and Social Disparities Social deprivation is accurately measured by levels of income inequality (Gini Coefficient), and is associated with very poor health outcomes A high supply of PCPs eliminates the adverse health effect of income inequality A high supply of PCPs eliminates racial disparities in health outcomes in rural and suburban populations (but not urban populations) Data from multiple studies in the United States, United Kingdom, Mexico, Costa Rica, and 7 African nations. Summarized in Starfield B, et al. Contribution of Primary Care to Health Systems and Health, The Milbank Quarterly, 2005;83:457-502

23. The Cost and Quality of Health Care The following slides are based on reports from the Dartmouth Center for Evaluative Clinical Science. The studies are population based ecological studies that use the state as the unit of care. Data are taken from complete Medicare data bases for several years in the late 1990s and early 2000s. Measures of health care quality are 24 surrogate markers for health care outcomes described by Steve Jencks in JAMA, and validated in many other studies.

24. Dartmouth Center for Evaluative Clinical Science Data Source: Medicare Data Base - 1995, 1999, 2003 State Medicare QIO Data - 2000, 2001 Unit of Care: State Method: Ranked the states using 24 recognized measures of health care quality, and compared quality to health care spending and the composition of the health care workforce Baicker K et al: Health Affairs, Apr. 7,2004 p.184f Fisher ES et al: Ann Int Med, Feb 18, 2003 p.273f Jencks SF et al: JAMA, 2000;284:1670-76 These 24 measures of health quality have been standardized by Steve Jencks and reported in 2000. They include both measures of inpatient and outpatient performance and measures of preventive medicine and disease treatment. Examples include appropriate screening for breast and cervical cancer, use of aspirin after MI, and use of warfarin for atrial fib.

25. This is an example of how the data are reported in the Baicker article. Each state is ranked by health care quality, and this is graphed against annual spending per Medicare beneficiary. There are 51 states because DC is included. The lower numbers reflect higher quality. As health care spending rises, quality declines significantly. Subsequent slides are based on the figures in the Baicker article, but leave out the points for each individual state.

26. I prepared the next few slides using data from the Baicker article. They are easier to read because the points for each state have been removed. The lines are the same slope and represent the same data from the article. The next slide shows that states at the 25 th percentile in quality ranking (lower quality) spend $1600 per year more per Medicare beneficiary than states at the 75 th percentile in quality (higher quality). There are 41.000,000 Medicare beneficiaries. If quality is improved from the 25 th to the 75 th percentile level, and $1600 per beneficiary were saved, this would translate into a $64 Billion savings for the system.

27. 25th Percentile Quality $6800 per year 75th Percentile Quality $5200 per year

28. The next 2 slides demonstrate how health care spending and quality for Medicare beneficiaries are related to physician supply. States at the 75 th percentile in quality have 56% more generalist physicians per capita (FPs, GIM and GPeds) than states at the 25 th percentile in quality (1.4/2.5 =.56) (Or, states at the lower end of quality had 36% fewer physicians than those at the 75 th percentile. 1.4/3.9 =.36) Likewise states at the 25 th percentile in spending (lower spending) have 58% more generalist physicians per capita than states at the 75 th percentile in spending. Significantly more family physicians result in significantly higher quality and lower cost (more than $1500 per person per year)

29. 25th Percentile Quality 2.5 per 10,000 75th Percentile Quality 3.9 per 10,000

30. 75th Percentile Spending 2.4 per 10,000 25th Percentile Spending 3.8 per 10,000

31. The next slide shows the relationship of the number of specialist physicians per capita and health care spending and quality. This slide is in no way a commentary on the quality of care delivered by individual specialist physicians, or on their training. The findings are clear and statistically significant. Those states with a higher ratio of specialist physicians per capita have significantly higher spending per Medicare beneficiary and significantly poorer quality of care indicators. These findings reflect a medical system that is grossly out of balance, operating on the left side of the curve in the second subsequent slide. This mathematical model shows, that were the physician workforce appropriately balanced (40-50% generalists among all physicians), the quality curves would have no slope. Of note, the Dartmouth studies also examined the ratio of nurses per capita, and found no relationship among nurses per capita and Medicare spending per capita or health outcomes.

33. US 2005-32% US entering residency classes – 2005, 2006 – 18% Off the curve

34. Generalist Medicine: Why is it so effective? When there are an appropriate number of generalist physicians operating in a health care system with appropriate characteristics, the following receive appropriate emphasis: –Primary Care Medicine –Preventive Medicine –Public Health –Personal Medical Homes (Well coordinated, personal medical care)

35. Health United States, 2005, CDC and National Center for Health Statistics

36. Blue Line - Health United States, 2005, CDC and National Center for Health Statistics Red Line - Percent generalist physicians projected if 18% of students entering residencies choose generalist careers.

37. GP Surg GIM GP + GIM + GPeds = 45% in 2004 British Medical Association Cohort Study Is there a trend in the rest of the world for fewer generalists? Not in the UK, as shown in this slide of data from the BMA Cohort Study, a study of arandom selection of medical students career paths.

38. Self-Reported Health - 2002 Men and Women Aged 55-64 Years (Adjusted for Behavioral Risk: Smoking, Obesity, & Alcohol) ConditionEnglandU.S. Diabetes 7.2 12.5* Hypertension 35.1 42.4* All Heart Diseases 10.1 15.1* Myocardial Infarction 4.2 5.4* Stroke 2.3 3.8* Lung Disease 6.2 8.1* Cancer 5.4 9.5* Numbers represent the percentage of respondents who report the condition * P < 0.01 Banks, J: JAMA 2006;295:2037-2045 England has a far higher proportion of generalists than the US. England reports better health outcomes across the board, and in this recent study, data from over 8000 people in the US Health and Retirement Survey and the English Longitudinal Study of Aging show that the English report a much better health status than Americans

40. Following is the presentation with the green commentary boxes removed

41. Health Care of the Future in the United States: The Imperative of Primary Care Jerry Kruse, MD, MSPH

42. Health Systems Part I Jerry Kruse, MD, MSPH

43. Ratio of Full-Time Equivalent Workers to Medicare Beneficiaries

44. In 2002, the US infant mortality rate rose for the first time in 40 years. The US infant mortality rate now exceeds that of Cuba and Costa Rica, and is twice the rate of Singapore The Infant Mortality Rate in the United States Lags Behind Other Industrialized Nations and the Gap is Widening

45. Percentage of Women ages 18 to 65 who had a Pap Test within the past 3 years (1987-2003) Source: CDC, National Center for Health Statistics, National Health Interview Survey Age Adjusted using the NCHS 2000 Standard Population

46. Percentage of Women age 40 or over who had Mammography within the past 2 years (1987-2003) Source: CDC, National Center for Health Statistics, National Health Interview Survey - Age Adjusted using the NCHS 2000 Standard Population

47. Comprehensive Review of the Effectiveness of Primary Care Contribution of Primary Care to Health Systems and Health Barbara Starfield, Leiyu Shi and James Macinko Johns Hopkins University, New York University The Milbank Quarterly, Volume 83, No. 3, 2005 Pages 457 - 502

48. Population-Based Health Outcomes In the modern, industrialized world, the nations and regions that place a relatively greater emphasis on generalist medicine and primary care have consistently better health outcomes.

49. Health Systems Part II Jerry Kruse, MD, MSPH

50. Family Medicine and Generalist Medicine: The Physician Workforce The emphasis that a nation or a region places on public health and preventive medicine is reflected by: –The percentage of the total health care budget spent on public health –The percentage of the total physician workforce that are primary care (generalist) physicians

51. www.eriposte.com/health/other/healthcare_US.htm http://www.oecd.org/dataoecd/59/49/35529832.xls Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, UK, US USA 23 Other Nations

52. Institute of Medicine Definition of Primary Care “… (1) the provision of integrated, accessible health care services (2) by clinicians who are accountable for addressing a large majority of health care needs, (3) developing sustained partnerships with patients, and (4) practicing within the context of the family and community…” Donaldson, IOM Report, Primary Care: America’s Health in a New Era, 1996 IOM Report, 1978 General Pediatrics: The Medical Home Family Medicine: The Personal Medical Home General Internal Medicine: The Advanced Medical Home The Patient-Centered Medical Home

53. Improving Health Outcomes for Populations Primary Care prevents illness and death through the following four mechanisms: 1. Supply of primary care physicians Ratio of generalist physicians to the total population 2. Supply of primary care physicians Ratio of generalist physicians to all physicians 3. Relationship with a source of primary care 4. Important features of the Health Care System Patient-Centered Medical Home

54. Health Outcomes and the Supply of Primary Care Physicians: US Studies States with higher ratios of Primary Care Physicians to population had significantly better health outcomes, including: a. Lower rates of All-cause mortality b. Lower rates of Heart Disease mortality c. Lower rates of Cancer Disease mortality d. Lower rates of Stroke mortality e. Lower rates of Infant mortality f. Lower rates of Low Birth Weight infants g. Better Self-Reported Health h. Longer Life Span Shi. Journal of Health Services, 1994:24:431-458 Vogel, et al. International Journal of Health, 1998:28:183-196 The studies controlled for sociodemograhic factors: %elderly, urban, minority, education, income, unemployment, pollution, smoking

55. PCP Supply and Health Outcomes: Summary of United States Studies There is a consistent relationship between more primary care physicians and improved health outcomes, regardless of: Year of study (1980-2000) Lag period (Length of effect) Level of Analysis (State, County or Local) Type of Outcome Shi. Journal of Health Services, 1994:24:431-458 Vogel, et al. International Journal of Health, 1998:28:183-196

56. The Effect of Physician Workforce on Health Outcomes Johns Hopkins Bloomberg School of Public Health: Six population-based studies of US, Canada, and Europe found that optimal primary health outcomes occur when 40-50% of the physician workforce are generalist physicians Dartmouth Center for Evaluative Clinical Science: Three studies using US nation-wide Medicare data bases found that quality health indicators are better and cost of care decreases as the number of generalist physicians increases.

57. Johns Hopkins Studies: Summary Primary health outcome measures – e.g., life expectancy, death rate, infant mortality rate, death rates from cancer and heart disease, etc.— are optimized when 40 to 50 % of the physician workforce is made up of generalist physicians Starfield B: British Journal of General Practice, April 2001, p303 Shi L et al: Journal of Family Practice, April 1999, p275 Starfield B: Health Affairs, March 15, 2005, p97

59. Primary Care Orientation: Practice and Health System Characteristics Nations, Counties and States with stronger primary care practices (personal medical homes) and certain health system characteristics have consistently better health outcomes, including: Lower all-cause mortality Lower neonatal mortality Lower cause specific mortality (Pulmonary Disease, Heart Disease, Cancer) Starfield. JAMA, 1991;266:2268-71 Starfield. Lancet, 1994:344:1129-34 Starfield, et al. Oxford University Press, 1998 Or. Health Care Mortality Across OECD Countries, 2001 Shi, et al. Health Services Research, 2002;37:529-550 Macinko, et al. Health Services Research, 2003;38:831-865

60. Practice Characteristics Associated With Improved Health Outcomes First Contact Care Patient-focused Care over time Comprehensive Care (Degree to which the primary care physician provides a broad range of health services) Coordinated Care Family Orientation (Degree to which medical services are provided to family member by the same provider) Community Orientation The Patient-Centered Medical Home Starfield & Shi: Pediatrics, 2004;113:1493-99

61. The Patient-Centered Medical Home Legislative Definition of AAFP, ACP, AAP & AOA Personal Physician Physician Directed Medical Practice Whole Person Orientation Coordinated and Integrated Care Quality and Safety Measures Evident EBM and Clinical Decision Support Voluntary CQI Patient’s Expectation Met HIT used appropriately Voluntary Recognition Process Enhanced Access Appropriate Payment

62. Health System and Policy Characteristics Associated With Improved Health Outcomes 1.Attempts to distribute health services equitably with respect to regional health care needs 2.Universal or near-universal financial assistance guaranteed by a publicly accountable body 3.Low or no co-pay for health services 4.Percentage of physicians who are generalists 5.Similar professional earnings of primary care physicians relative to other specialties

63. Primary Care and Social Disparities Social deprivation is accurately measured by levels of income inequality (Gini Coefficient), and is associated with very poor health outcomes A high supply of PCPs eliminates the adverse health effect of income inequality A high supply of PCPs eliminates racial disparities in health outcomes in rural and suburban populations (but not urban populations) Data from multiple studies in the United States, United Kingdom, Mexico, Costa Rica, and 7 African nations. Summarized in Starfield B, et al. Contribution of Primary Care to Health Systems and Health, The Milbank Quarterly, 2005;83:457-502

64. The Cost and Quality of Health Care The following slides are based on reports from the Dartmouth Center for Evaluative Clinical Science. The studies are population based ecological studies that use the state as the unit of care. Data are taken from complete Medicare data bases for several years in the late 1990s and early 2000s. Measures of health care quality are 24 surrogate markers for health care outcomes described by Steve Jencks in JAMA, and validated in many other studies.

65. Dartmouth Center for Evaluative Clinical Science Data Source: Medicare Data Base - 1995, 1999, 2003 State Medicare QIO Data - 2000, 2001 Unit of Care: State Method: Ranked the states using 24 recognized measures of health care quality, and compared quality to health care spending and the composition of the health care workforce Baicker K et al: Health Affairs, Apr. 7,2004 p.184f Fisher ES et al: Ann Int Med, Feb 18, 2003 p.273f Jencks SF et al: JAMA, 2000;284:1670-76

67. 25th Percentile Quality $6800 per year 75th Percentile Quality $5200 per year

68. 25th Percentile Quality 2.5 per 10,000 75th Percentile Quality 3.9 per 10,000

69. 75th Percentile Spending 2.4 per 10,000 25th Percentile Spending 3.8 per 10,000

71. US 2005-32% US entering residency classes – 2005, 2006 – 18% Off the curve

72. Generalist Medicine: Why is it so effective? When there are an appropriate number of generalist physicians operating in a health care system with appropriate characteristics, the following receive appropriate emphasis: –Primary Care Medicine –Preventive Medicine –Public Health –Personal Medical Homes (Well coordinated, personal medical care)

73. Health United States, 2005, CDC and National Center for Health Statistics

74. Blue Line - Health United States, 2005, CDC and National Center for Health Statistics Red Line - Percent generalist physicians projected if 18% of students entering residencies choose generalist careers.

75. GP Surg GIM GP + GIM + GPeds = 45% in 2004 British Medical Association Cohort Study

76. Self-Reported Health - 2002 Men and Women Aged 55-64 Years (Adjusted for Behavioral Risk: Smoking, Obesity, & Alcohol) ConditionEnglandU.S. Diabetes 7.2 12.5* Hypertension 35.1 42.4* All Heart Diseases 10.1 15.1* Myocardial Infarction 4.2 5.4* Stroke 2.3 3.8* Lung Disease 6.2 8.1* Cancer 5.4 9.5* Numbers represent the percentage of respondents who report the condition * P < 0.01 Banks, J: JAMA 2006;295:2037-2045