Sunday, February 3, 2008
Lack of Primary Care Will Derail Reform
Health care reform is dead in the water unless we fix what is going on with primary care medicine in this country.
Let's just play this out. We have about 47 million uninsured folks in the U.S. There aren't too many people who disagree with the need for universal coverage for all Americans. (How we pay for it is another topic... but expanding coverage is just good policy). At the same time as we are expanding coverage, the numbers of physicians in training who are choosing primary care medicine has fallen to 15%. That means 85% are deciding that specialty medicine is the way to go.
Most patients will not have a comprehensive primary care doctor who knows them, knows all of their health issues, makes sure they get preventive care and coordinates care. There just won't be enough primary care doctors to go around and the ones that have experience and good bedside manner will limit the number of patients in their practice by charging retainer fees (AKA: concierge medicine).
Here is what happens when a patient doesn't have a primary to call:
A patient with knee pain and joint stiffness may see an ortho doctor who will do X-rays and maybe an office MRI ($275 for comprehensive office visit, $400 for X-ray, $550 for office MRI). He prescribes pain medicine and informs her that there is no surgical diagnosis. Still in pain, the patient decides to see a Rheumatologist. At the Rheumatology office the X-ray might be repeated ( $250 comprehensive exam, $400 X-ray) and a collagen vascular blood panel will be run to rule out lupus, rheumatoid arthritis, infection and PMR, ($375). The patient is given a medication for pain but it interacts with the other pain med so now the patient ends up with abdominal pain.
The patient calls the Rheumatologist who says "Go to the ER" and tests are done there to look for an ulcer or GI bleed. ($4500 for 10 hours in ER). No active bleed is seen so the patient is referred for follow up to the Gastroenterologist ($275 comprehensive exam, $150 blood tests, $2200 upper endoscopy, $2200 colonoscopy)
By the way, the knee pain persists and the patient never does get anyone to coordinate physical therapy, which is what she needed in the first place.
This is not an indictment of specialty medicine. A specialist has a narrow scope of vision and that is what makes them valuable when we want to zone in on a problem. But what we are really lacking is a comprehensive physician who can diagnose, follow and coordinate the complex health needs of a patient.
The AMA has failed primary care and in some ways actively sabotaged it. Medicare (CMS) and Congress have driven the nail in the primary care coffin by underfunding and underpaying primary care for years. The federal government has abdicated responsibility for redesigning Medicare payment policies and these payment practices are carried into the private insurance market, further worsening the problem.
Unless immediate and comprehensive reforms are implemented, primary care, the backbone of the U.S. health care system, will collapse. Residents have already abandoned primary care as a career choice but I have no doubt we can get them back if we improve reimbursement and stature of the profession.
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