Matthew Holt

The result of the primary care crisis

Over at Spot-on I’m writing about the primary care crisis in partial response to the great stuff from Bob Wachter last week on THCB and also from Maggie Mahar and Brian Klepper. Hopefully, it’s a primer for the politico types over there about the primary care crisis and also what the likely results of it are. Hint, no pay equality, but more retail clinics and online visits.

Meanwhile, my piece at Spot-on two weeks back about the Two Ted Kennedy’s appears rather smarter than it probably was given the long piece in the NY Times today about exactly how risky his surgery was and exactly the level of agreement (i.e. not much) that existed among the wide medical team he convened. Evidence based medicine? Well let’s just say that the oft heard rumors of Medicare’s impending bankruptcy may be truer than I tend to believe if every patient wants that level of service.

At any rate, please take a look at the new piece and the older piece and as ever come back here to comment.

Ask any health care wonk and they’ll tell you that within the larger
health care crisis is a primary care crisis. There is more and more
demand for primary care physicians – the person you probably call your
"family doctor" – but America’s medical schools are producing fewer of
them.


Why? Well in a word, money.

It’s not actually medical school that’s the problem. It’s what happens next. A newly graduated physician, looking a big chunk of debt used to pay for medical school tuition gets to chose their residency and, as such, decides what type of doctor to become.In the U.S. we let medical students choose what to do. Not being dummies, most of them notice that diagnostic radiologists and orthopedic surgeons make three times what primary care doctors make, and choose their career path accordingly. Why the vast difference in compensation? Doing something to a patient – fixing a broken hip, reading an x-ray – has always been better rewarded more than talking to them about their high blood pressure or their son’s excema.

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11 replies »

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  2. With the primary care crisis pending, there is also a major allied healthcare skilled worker shortage. According to a new study by the Imagine America Foundation, the U.S will need to fill the jobs of nearly three million healthcare professionals. To find out more about the study on the impact of career colleges on America’s skilled shortage, see http://www.imagine-america.org

  3. > It would be interesting for someone to eventually do
    > a calculation on the cost of Kennedy’s surgery and
    > current adjuvant therapy vs. the
    > radiation/chemotherapy recommended initially.
    This is the kind of thing England’s NICE does, but they don’t name names . My bet is they’ve already got it done for the Senator’s condition. They probably have a QALY estimate for both treatment modalities as well.
    t

  4. If we ever move from a fee for service payment model to capitation, I can envision hospitals bidding up salaries for primary care doctors who can keep patients healthy and out of the hospital while hospitalists are paid to manage and coordinate care for inpatients.
    In the meantime, there is no reason why we cannot make much greater use of NP’s and PA’s. There are already over 1,000 health clinics in retail stores staffed mainly by NP’s, and there hasn’t been a single malpractice suit so far. Health plans offer hotlines staffed by nurses using computerized decision support tools. They can help members determine whether their problem is serious enough to go to an emergency room if they cannot contact their doctor or whether it’s something that will resolve itself aided by some simple advice regarding diet, OTC medications, etc. I’ve used this service myself and was very satisfied.
    Interestingly, I attended a panel discussion on healthcare at the University of Pennsylvania two months ago sponsored by the U of P’s School of Nursing. One of the experts on the panel grew up in Copenhagen, Denmark. She said that an NP in the U.S. has as much education as a primary care doctor in Denmark. She also claimed that an NP can handle up to 85% of all primary care as well as a doctor can. Doctors, for their part, resist greater use of NP’s because they don’t appreciate the competition. Of course, if most doctors were in practices sufficiently large so they could offer patients evening and weekend appointments, the NP staffed retail clinics probably couldn’t survive, but that’s a separate discussion.

  5. There may indeed be a shortage of specialists coming but those projections numbers have been notoriously flawed and inaccurate. Plus, you have to look at the sources of the projection data as some have a very vested interest in generating sensational numbers.

  6. Peter and Tom – actually, that was precisely the point I was trying to make (obviously, not very well) – that there is accumulation of evidence on a given condition and then there is interpretation of that evidence – multiplied by the variables within each individual case, and the chronologic evolution of medical technology. This is one reason why evidence-based medicine is so difficult – there is rarely a black/white dichotomy between what is the best treatment for a condition and what is not. Also, the evidence-based best treatment is continually evolving with new knowledge. Who knows if a policy of aggressive surgery for glioblastomas, with modern surgical techniques and superior imaging capabilities, may work now, when it hasn’t in past years with different techniques and resources? Or is the Duke surgeon just one of those who subscribes to ‘a chance to cut is a chance to cure?’ (and there are many of them).
    The conundrum I referred to is that society has to decide whether to include economics within the ‘evidence’. Should cost-effectiveness be included as ‘evidence’? Should patients like Kennedy with the means to pay for non cost-effective, but possibly medically effective, treatment be allowed to? Should a therapy be regarded as effective if it adds one year or less to life, or only 2 years or more? What about metastatic cancers like Elizabeth Edwards’, where cure is not even in the equation? Should we say treating them is not cost-effective? I don’t know the answers.
    It would be interesting for someone to eventually do a calculation on the cost of Kennedy’s surgery and current adjuvant therapy vs. the radiation/chemotherapy recommended initially. One would have to include costs of any ‘salvage’ therapy used if the tumor recurs post-surgery, and also factor in his survival time.
    Cold-hearted, perhaps, but maybe illustrative.

  7. It is true that there is a financial disincentive for people to choose primary care out of medical school. However, this alone does not explain the shortage of primary care physicians. As it turns out, there is a projected shortage of physicians in general (see the AAMC website at http://www.aamc.org/workforce/).
    Interestingly, even specialists are in short demand. In the AAMC report listed above, it is noted that many states report shortages in specialties including allergy and immunology, cardiology, child psychiatry,dermatology, endocrinology, neurosurgery, and psychiatry.
    In 2004, Merritt, Hawkins & Associates, a health care staffing and consulting firm, predicted a shortage of 90,000 to 200,000 physicians overall. Furthermore, they estimated that average wait times for medical specialties would increase dramatically from the current two weeks to five weeks.
    Primary care physicians do great work and their compensation should reflect their contribution. However, a bigger crisis looms if the few primary care physicians we have cannot refer their patients for surgery or to have pacemakers placed.

  8. Gee, Dr. Bev, I think you’re confusing two concepts:
    1) developing evidence
    2) applying evidence
    Medical Research probably should not be thought-of as “medicine”, and probably should be carried-out by doctors courageous-enough to work for academic salaries. Therefore one may indeed apply a uniform and permanent EBM ruberic for MEDICAL reasons.
    t

  9. Bev, I agree to a point, but why should there be only two people involved in the decision – the doctor, who gets paid when he/she operates using someone else’s money, and the patient, using someone else’s money, and therefore has nothing to loose. If we went with this thinking then who stops all the Mickey Mantle decisions? Is every Terri Schiavo worth keeping on life support waiting for God to perform a miracle? Would a medicaid patient get to go to Duke and obtain the same try? I know this dicussion goes around in circles forever but there must be a better way if we are going to avoid bankrupting the “system”.

  10. From Matt’s spot-on piece on primary care:
    “And the U.S. is not seriously going to tackle – let along address – this problem as a matter of public policy until the whole system breaks so severely that more people demand massive reform.”
    This was one theory expressed at Academyhealth’s scientific meeting in June. It was loving designated the “cockroach scenario.” After the U.S. health care apocalypse, only primary care will survive…or so goes the theory.
    I’d hate to think this was our only option to fix physician payment policy. I agree that this whole issue will always be relatively invisible to the public, but I don’t think we need public uproar. What we do need is a well-placed reformer in the executive branch who will listen to enlightened bodies like MedPAC and sever CMS’s relationship with the RUC. After all, the RUC has never had any legislative authority except–curiously–for its mention in legislation authorizing the Medicare medical home pilot.
    On the subject of virtual PCPs, I would’ve believed this was a great idea if you’d pitched it to me before I started getting comfortable in my primary care clinic (towards the end of my residency). What’s hard to appreciate without clinical training is the importance of nonverbal dialogue and physical examination in the primary care relationship. A good PCP uses these tools every day to make sound clinical judgements…not to mention saving millions of dollars in diagnostic tests and procedures over the course of a career. Most of what I see in clinic is not routine, guideline-based chronic care. Ordering screening tests and titrating blood pressure medication has never required a medical degree. It’s in the diagnostic dilemmas that the classical cognitive medical skills (interviewing and examining) really matter.
    I suppose a true AI–a program capable of passing some kind of medical Turing test–could conceivably achieve this kind of expertise, but this sounds even less probable within our lifetimes than the cockroach scenario. A more likely result of using virtual PCPs will be excessive diagnostic testing, since computers can more easily interpret numerically coded test results.

  11. Kennedy’s case is an excellent example of why evidence-based medicine will never translate into a “cookbook” of completely standardized practice. As a pathologist who has looked at this nasty tumor under the microscope too many times, glioblastoma is almost uniformly fatal within, at most, a few years. But each patient’s tumor, and each patient’s age and medical background, and each patient’s will to fight, is different. Also, many medical advances are made by doctors courageous enough to defy standard opinion who achieve good results and then over time develop a track record to make their treatment an accepted and evidence-based one. Therefore, one cannot apply a uniform and permanent EBM rubric of – gonna die anyway, don’t operate – to all glioblastoma patients for MEDICAL reasons. However, one COULD apply it for social/political/economic reasons, and therein lies the basic conundrum before us.

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