Two recent posts by Matthew and Bob Wachter on the crisis in primary care sparked great debates in the comment sections.
Matthew’s inference that Medicare’s bankruptcy will be fast upon us if everyone with brain cancer received an experimental surgery like Sen. Ted Kennedy recently had evoked this response from Bev. M.D.
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.
Deeper in the comments, Peter wrote:
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 discussion goes around in circles forever but there
must be a better way if we are going to avoid bankrupting the "system."
In his post, Wachter wrote that the primary care crisis is not a future problem but one of the here and now, citing evidence that even connected doctors cannot get primary care appointments.
Jeff Goldsmith wrote that part of the solution is for Medicare to pay for relationships and for medical schools to foster a culture of respect for primary care.
So many of the "appointments" we cannot get are for getting
questions answered that if we had a relationship with them, we could
get answered by phone, text or e-mail. … It isn’t just money that PCP’s lack, but respect. So just paying
more may not be enough. A lot of the reason why young internists do not
enter general practice can be traced not only to a lack of money, but a
lack of respect in med. school/teaching hospital peer culture. A lot of
medical school faculty believe that primary care is simply unnecessary,
in part because they triage themselves, so see no need for this
function for the rest of us.
JD thinks that six-figure medical debt contributes to the shortage.
My hunch is that despite all the complaints about pay, if this huge
obstacle to bringing new people into primary care were eliminated, we
would see a surge of new PCPs. It would open up the profession to
motivated people from families in the lower 60% of the income scale. That’s not to say we don’t need to fix the reimbursement system. We do.
Evidence based medicine will never substitute for a well trained, astute experienced clinician. Throwing more doctors, nurses and money at the problem has not worked in the past nor will it work now. The reason that the U.K. is succeeding in controlling health cost certainly is not for the want of more doctors, though its quite possible that we need more nurses. In my expert opinion, credentials will come later, the reason for the U.K.’s success is that the system is based on getting people on their feet and keeping them healthy.
In a report by Wenberg at USC, more doctors resulted in higher cost care, more utilization of specialties, fewer identifiable primary care physicians and documented poorer medical outcome.
In studies of medical care, cost and results individual States, Florida, Massachusetts, and California ranked among the highest in financial expenditures per patient, while they had definitively poor medical outcomes. Furthermore, these States have the largest per capita number of physicians.
A part of the medical system failure in this country is that hospitals, as a result of DRG’s, and payer, through payment caps, HMO, and PPO(to a lesser degree) have squeezed the primary care physician beyond their resources resulting in sicker less functional patients are leaving United States hospitals, offices and clinics.
More money in itself doesn’t work primarily because United States medicine is predicated on an illness based system with illness based doctors. In another study by Wenberg published in the NEJM found that the amount of medical specialist was directly related to the number of procedures for that specialist that were done. The more ENT doctors the more ENT procedures. The more OB-Gyn’s the higher the C-section rate and on and on.
Imposing DRG’s and medical payment caps by utilization control nurses is resulting in a dismal failure in overall medical expenditures. This type of cost containment merely pushes more sick people back on the streets or it results in escalation of medical diagnoses with more specialist requirements. The golf courses fill up and there are more boats at the marina. Patients are likely undergo more medical testing and trivial problems get medicalized.
I do believe that the United States does has a desperately needed gift to offer the world of medicine. The introduction of a physician centric information systems with more timely, accurate and well presented information systems can save physician time by up to 70% in my opinion. The presence of high quality information can lower hospitalization and specialty consultation rates by considerable amounts. Emergent complications are less likely to occur redundant procedures would be obviated and health happy patients would return to the streets.
Lest we worry about hospitals and doctors going broke, it doesn’t take too much of a stretch of the imagination to realize such an approach to medicine stands to garner considerably more profit for both providers and payers. This becomes considerably more important as the health dollar shrinks precipitously as the baby bloomers reach Medicare age. In other words, this approach should be able to more than pay for itself in a Capitalist Environment.
Lest those who are among the few who feel that their solution is to accrue a medical war chest to prolong their lives with large sums of money, let me remind you that are “best medical centers” with “the best medical system” are still working under the same systems.
Finally it is medical infrastructure with support of timely, appropriate information, presented to the right person at the right time that is a novel but not particularly revolutionary solution to some of our problems.
I intend to promote these solutions here and the fledgling blog at firstname.lastname@example.org and invite comments.
Bev MD: As a non-clinician I really can’t comment on how Kennedy would have been treated under the NHS. It would be wrong of me to do so. It’s quite possible he would have received world-class care with innovative drugs and procedures (as has happened with folks we know here with serious cancers). I just don’t know.
As an American citizen who’s been in the UK for two years with a young family, I can say I’d take the NHS over what we had in the States any day. (Straw poll of one.)
There is an inherent tension between populations and individuals, EBM and individual clinicians, macro policy and frontline policy. I think it’s a healthy tension, a frustrating tension, but a necessary tension that recognizes the complexity of treating huge populations as cost effectively and equitably as possible.
Matt Holt’s take in the previous post is spot on.
Primary care as a specialty is dead and it’s place is being taken by nurse practioners and other “ancillary” providers of care. Providers who by the way, (mostly) lack the professional self-confidence and moxy to push proceduralist to deliver cost effective care. Nothing wrong with this transition, given how our government pays for care, it is the natural consequence. It is apparently what is desired.
I do have to take issue with him on one statement, that these changes are not good for Primary care Physicians. As an MD Family Physician with essentially no competition, I can set my own price for my services, a price which in our affluent society enough folks can pay so that I make as much as the average orthopedist with less risk. I also care for only about 100 families on retainer ( at 5-10k per year per family) as opposed to the 3200 folks who called me their doctor under FFS.
These changes are very, very good for us FPs left and very, very, very bad for those who have to figure out how to provide cost effective, high quality care to the population.
I assume you are in the UK. Can you tell us what would have happened to Senator Kennedy’s case there? I think many THCB readers think they know the answer but it would be good to hear it from the horses’ mouth so to speak.
[quote]Kennedy’s case is an excellent example of why evidence-based medicine will never translate into a “cookbook” of completely standardized practice.[/quote]
I work for a company that provides evidence-based services to help NHS groups optimise the configuration and purchasing of health services. EBM needs to get beyond being seen a tool for ‘cookbook medicine’, and many in the EB community need to get back into the clinical and commissioning trenches where nothing is black and white, cut and dry. Or as one person (I forget who) said: You love NICE until a loved-one in your family is denied a treatment. The goal of EBM explicitly shouldn’t be to cookbook-ize healthcare, but to apply scientific research to macro and micro-level decisions sensitively, taking human beings into consideration, while trying to balance the need for innovation with the need for cost control. It’s possible. Just difficult. And not the big ‘miracle cure’ for exploding budgets that some have sold EB to be.
In life or death situations, one must make judgements based upon the preponderance of available evidence as opposed to proof beyond reasonable doubt. It seems obvious that evidence-based medicine proponents may fail to apply this common sense standard on a consistent basis.
In cancer medicine, there are limitations involved with randomized clinical trials. Perhaps the greatest limitation is that it is predictive of population trends, and is not definitive. Clinical trials provide few black and white answers. The problem with the empirical approach is it yields information about how large populations are likely to respond to a treatment. Doctors don’t treat populations, they treat individual patients. I’m sure Ted Kennedy would appreciate that.
Because of this, doctors give treatments knowing full well that only a certain percentage of patients will receive a benefit from any given medicine. They subject patients to one type of therapy after another, just going from one journal paper to another journal paper. They need information about the characteristics that predict which patients are more likely to respond well. The empirical approach doesn’t tell doctors how to personalize their care to individual patients.