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.


Anonymous said...

I agree that lack of primary care creates quality issues, and raises costs. The patient with knee pain is a good example.

Question: Do you need an MD or DO to be a good primary care doc, or can (should) this role be assumed by non-physician licensed practitioners?

This is an important, and difficult question given the low number of med students going into primary care.

K said...

I'm wary of NPs or RNs doing primary care, if only because of a particular incident where a nurse practitioner told me to do one thing, and a doctor who saw me later told me that that was essentially the very last thing I should ever have done under the circumstances (and based on what it was, I'd have to agree).

Quite honestly, if medical school wasn't so dang expensive, and if my gag reflex wasn't so fantastic, I might seriously consider, even at my old old old age, becoming a primary care doc (though Mom keeps telling me going into accounting is a more stable option than anything else :D).

Barbara K. said...

I am lucky to have a PCP who has three special qualities:
He stays current with research in a range of health areas
He knows how to listen (and he trusts me)
He knows when he doesn't know something.

We don't just need more PCPs. We need more PCPs who are superb.

Anonymous said...

We don't just need more PCPs. We need more PCPs who are superb.

In times of crisis, beggars can't be choosers. The building's on fire, someone shows up with a ladder, are you going to question if it's OSHA compliant?

This will get far, far worse before it gets better. Politicians don't prevent change proactively, especially when the cost is now but the benefit is later. When the above-mentioned fire is raging, serious corrections will occur. Unfortunately, the return to normalcy from chaos also is a delayed-returns situation.

Healthnut said...

I'm not sure if it will be fixed. I have the strange feeling that the govt. will not intervene.

1) Cardiovascular disease and cancer are the two leading causes of deaths in the US. Both are very costly procedures. If this is such a huge concern to the US government, the government will by now have banned transfat including the usage of Vistive. Transfat was invented in the 1930's. Why is transfat still allowed on the market?

2) Insurance is a business entity and part of the private sector. The government can only fine a business, but it can't control it.

3) Lastly, the US govt. has TOO MUCH DEBT and cannot afford to intervene. Already, we are seeing major Treasury buyers like Japan and China looking elsewhere to park their money. This is the main reason behind the dollar continuing to devaluate. Japan and China roughly holds 50/50 in US Treasuries. There are other countries involved but are very insignificant.

Healthnut said...

And here's a good example of the govt. not doing anything.

FEMA Covered Up Cancer Risks to Katrina Victims

Raymond Bouchayer said...

Life is the greatest cause of death and Insurance companies will try to keep you alive as long as possible or at least until you go broke , whatever comes first

Gervais said...

It will not really have success, I feel this way.
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