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1. I am asthonished about the appointment times you report. In my area, PCP visits are 10-20 minutes (I do agree that this is too short, esp. for complex patients), my own (nonsurgical specialty) slots are on the generous end with 30 minutes (most of my colleagues offer 15 or 20 minutes for f/u).
   How can a nonsurgical specialist afford offering 60 minute visit times for f/u visits? And what do you do with 45-60 minutes face to face time?

2. Going back to the original line of commentary (though I think torte reform is a very interesting issue as well), a huge issue with PCPs being able to manage chronic care cases is the availability of PCPs. I have a minor chronic condition that easily could have been managed by my PCP, though I now see an endocrinologist for it. Frankly, it’s probably for the best because in order to see my PCP I have to book an appointment 6 months in advance, whereas I can get in to see my endocrinologist with less than a month of lead time. Additionally, I don’t know exactly how long they book the PCP appointments for, but I’m guessing it’s 20 to 30 minutes, whereas my endocrinologist books appointments for an hour.
   How can a PCP manage a chronic condition if s/he has no free appointments for extended periods of time and has no time to spend with an individual in those appointments. Of course they’re going to refer.
   There are two problems that I can think of that contribute to scarcity of PCP availability. 1) shortage of PCPs, though in the Boston area I believe there is a shortage of a number of specialists too and 2) repayment systems, such as capitation, that emphasize quantity or quality.
   PCPs need to be paid comparably to specialists. This will help to de-incentivize entering speciality fields and encourage more physicians to become PCPs. Additionally, they need to be paid in such a way as to enable them to limit their case load so that they can play the role that PCPs are supposed to, as the overall manager of a patients care, including in some cases chronic conditions.

3. rbar, yea, maybe the “few account for the most” is a myth. I tried a short search but did not find much. It may be regional or even local – bad doc(s) and agressive lawyer(s) in one city. Here’s an AARP link with some info:
   http://bulletin.aarp.org/yourhealth/articles/righting_wrongs.html

4. Peter,
   I heard this (“Last I read was that a small portion of docs are responsible for large portion of law suits.”) but I don’t think it’s accurate – do you have a source? I don’t have a source (yet, but I could look it up if you’re interested) for what I remember: that the percentage of doctors being sued once during their career is extremely high.
   You are absolutely right that the fear of being sued makes doctors more careful. If you reduce the tort signal, you may produce more negligence since there is overlap between appropriate care and defensiveness (in other words, in rare cases, the test ordered out of defensiveness may be a blessing for the patient; but this is outweighed by complications of invasive measures and the economic costs of doing all these tests). And in the current system, there is little if any discrimination between appropriate and inappropriate care (look at the Harvard review studies, I can give you the source on request). To avoid senseless defensiveness and to have a reasonable tort signal, I’d suggest the following:
   -case review by independent doctors out of area
   -punish failure to diagnose only for the most obvious misses, or if they occur repeatedly (the boards could do that)
   -strictly enforce obvious failures of professional conduct (e.g. not seeing patient timely, not documenting exam, not following through with an important test result central to the condition in question, not referring for a 2nd opinion for a patient with unexplained complaints/findings)
   In other words, if a doctor makes a reasonable effort and documents that, he/she can feel protected, even if he turns out to be in error (if he doesn’t, he knows that he/she is at risk for litigation). If he fails repeatedly (on intellect, not on effort), his license may be revoked (after this has been scrutinized).

5. rbar,
   The intra state variation is important if those who think our tort system is out of control believe it drives medical costs – I think it may, but not nearly as much as econimic incentives to over treat.
   It would be nice to restructure lawyers agressive hunt for money, but my point was that those who cry fowl the loudest don’t want their right to sue taken away – just the other guys. Just a point, nothing more.
   Real life attempt that my sister-in-law had trying to find a lawyer to consult about mistreatment at a hospital her father was in.
   The fact that lawsuits are allowed to exist makes everyone more careful about negligence – docs and ordinary citizens. What is really needed is better oversight by doc guilds. Last I read was that a small portion of docs are responsible for large portion of law suits. How much do you want to indemnify docs? Certainly no chance of lawsuit would be nice for them but would it not make them more careless? As I said, if medical bills were covered under single-pay that would take a huge portion of damages off the table. I’d also be for capping legal fees, but you have to remember that medical lawsuits are expensive to maintain also for the plaintiff. How do you also make legal access affordable. As you know, when a lawsuit is launched against hospital staff the hospital does an internal investigation to see if there is a case worth defending. Certainly the plaintiff’s lawyer does not want to spend free legal time pursuing a hopeless case. These are also the factors that keep suits down.

6. Peter, you make some points that sound reasonable and deserve a rebuttal:
   >>Show me lower medical spending/costs in states with malpractice “reform”.<>Most people who want lawyers restrained (myself included to a point) also want the best, meanest, most agressive lawyer they can find when THEY are wronged.<>Here’s a tactic hospitals are using. They hire many local lawyers for ordinary legal issues, then when a patient (usually local) attempts to find a lawyer for malpractice, the lawyer says that he/she would have an ethical conflict of interest because they have done business with the hospital.<<
   Never heard of that (do you have a source?). The TV and yellow pages ads in my supposedly "physician friendly malpractice environment" tell me that malpractice lawyers are active, well and – accessible.
   And this is the major point: it does not even matter that much how often doctors get succesfully sued – the fact that you can and might be sued is enough to trigger defensive behavior. A lawsuit is perceived, wrongly or not, as a threat to a doctors career, expertise, integrity and financial health; and at the very least, a trial means many hours of uncompensated, painful work on the side, followed by a week or two of the same pain and anxiety fulltime (at trial).
   

7. An evidence based decision support tool doesn’t have to be high tech. A ring binder with periodic paper updates would do the trick. I personally rely on “Up to Date Online” for that kind of information. There needs to be some legislation that says that if I do what the experts recommend and a bad outcome occurs, then I can’t be sued. Right now there is no protection. The John Ritter case and the Terry Schiavo case are two high profile cases where doctors did everything by the book and got sued anyway. My own recent experience with a smoker who sued after she was diagnosed with lung cancer is another one. There are no screening tests recommended for lung cancer. I don’t know that there is much political will to fix the malpractice problem (my team won’t even acknowledge that it exists!) Unfortunately the Democrats tend to side with the trial lawyers and the Republicans have no interest in actually passing legislation that will help anyone other than large corporations.
   Although I think that Peter’s statement about the European costs is true, there is far more to the difference between the European and American approaches to malpractice. I’m not a social scientist or legal scholar and don’t know how you would go about finding actual research, but I talk to a lot of people and see a lot of anecdotal data. One of the few things that I remember from a driver’s training course that I took in Germany was that the European legal system implicitly gives you the right to assume that other people will behave in a rational manner. If the person ahead of you slams on his brakes and you rear-end him, it may not be your fault. If a doctor tells you to follow up test results and you don’t, your widow can’t sue the doctor for $68M, even if you are a beloved TV star.
   Even when doctors do make mistakes in Europe, they are far less likely to be sued. Last year when I was in France there was a story on the news several days in a row about a family that was attempting to sue a doctor who had left a surgical implement in a patient that led to death from peritonitis. I don’t remember what the hang up was, but the idea was enough of a novelty that it made the local news. There is also a strange belief about outcomes in this country. Last week I was talking to a new patient, an Irish R.N., and I asked her about her parents’ causes of death. She laughed and said, “I don’t know, it was in Ireland and we expect people to get old and die there. It’s not like here.” Several of the docs in my practice recently won a very large malpractice lawsuit over a man who lingered for several years before dying in his mid-80s of multiple myeloma. (He had a bowel perforation a year before he died and the family sued saying that if he had had a CT when he first developed constipation from narcotics and several days before he developed belly pain, he would have avoided the perf — again not likely.)
   As is often the case when doctors get together, we’ve drifted off topic and into discussing malpractice. So wrenching the conversation back to the original question; you have to identify the actual causes of the problem before you can fix it. The rising cost of health care has a lot of causes. Some of that is improved technology; people are much less likely to die of MI than they did 30 years ago. Defensive medicine is a big part of the problem. Economic, cultural and education factors that push patients in the direction of more fragmented and more expensive specialist care are a big part of the problem. Poor record keeping and lack of communication tools is a part of the problem, but not I suspect as large as some think (remember I’m an ex-software engineer; I’m naturally pro-big software) and pushing docs into the acquisition of expensive and poorly designed EMRs benefits no one but the EMR vendors. With my systems engineering hat on, I tend to see the inefficiencies in the design of delivery of medical care, but at the same time the French provide excellent medical care without “medical homes” and with mostly traditional private and small group practices.
   Anyway, it’s an interesting problem, I hope that someone smarter than me can solve it.

8. “The concept itself has gotten distorted over time. Compensating for “damages” is one thing, but “pain and suffering” needs more deliberation.”
   Deron, the pain and suffering award is what pays the lawyer while leaving the damages for the patient. People need to understand that when a law suit is filed the lawyer has next to no information whether the suit has merit. That’s what the discovery process is for. Maybe if hospitals had more transparency and discussed outcomes with patients there would be less need for lawyers.
   Here’s a tactic hospitals are using. They hire many local lawyers for ordinary legal issues, then when a patient (usually local) attempts to find a lawyer for malpractice, the lawyer says that he/she would have an ethical conflict of interest because they have done business with the hospital. The patient is required to travel to find a lawyer, which helps frustrate the process. Now there’s a patient centered solution.

9. Great post! i especially found it useful where you stated. The U.S. government’s anniversary bill for healthcare spending – $3,925 per actuality – decidedly exceeds that of all added nations. Despite this, our accepted bloom affliction arrangement is more declining both patients and medical practitioners.

10. The points on malpractice and defensive medicine are all well taken. It’s a topic that comes up a lot in our medical group and I discuss it on my personal blog. Clearly, we could not have an ideal healthcare system without addressing defensive medicine.
    However, I think we need a game plan for getting reform efforts started. We’re not going to solve every aspect of our problems in the beginning. That’s why we have to keep it simple in order to get started. If we work on rebuilding our primary care system, we will be in a better position to address some of the other high cost drivers in the system. In fact, our approach to addressing the other issues could be different once our delivery system is in better shape.
    I agree that reducing defensive needs to happen fairly early on though. That’s where there the development of an evidence based decision support tool would be helpful. If physicians can demonstrate that they followed documented practices, they can make a stronger case for their treatment plans. I also think we need to better define “malpractice”. The concept itself has gotten distorted over time. Compensating for “damages” is one thing, but “pain and suffering” needs more deliberation.
    In a nutshell, I think narrowing the focus to get started might get things off the ground faster. Thanks for the comments so far. I’d love to hear more from all of you on this!

11. j, don’t forget that patients incur no medical costs at the VA, and most likely in Europe when there is a mistake. Take medical costs off the table and that would lower awards. Canada does have a higher legal sue threshold and Ontario at least pays half the malpractice premiums for docs.
    Show me lower medical spending/costs in states with malpractice “reform”. Lefty/righty, I think your statement; “There are any number of motivations that influence the decision to order a test or procedure and I don’t know how you would go about designing a study that would effectively estimate the percentage that is attributable to defensive medicine.”, is more to the point. Most people who want lawyers restrained (myself included to a point) also want the best, meanest, most agressive lawyer they can find when THEY are wronged. I think most lawyers make their money on NOT going to trial but fishing for settlements. Trent Lott (R-MS), one of the most vocal political voices against, “trial lawyers” sure went out and got his “trial lawyer” when he was denied coverage on his home after Katrina. In fact he hired the same lawyer that won the Tobacco Lawsuit, which was opposed by southern states, but who lined up for the money afterward. What’s that saying about, “cast the first stone”?

12. I’ve seen the statistic about European and U.S. generalists quoted in multiple locations including this very blog. I haven’t bothered to trace it back to its source to see if the numbers are valid, but anecdotally it sure seems that way.
    I agree with you about the cost of defensive medicine. The cost of defensive medicine is just one of those statistics that is very hard to estimate. There are any number of motivations that influence the decision to order a test or procedure and I don’t know how you would go about designing a study that would effectively estimate the percentage that is attributable to defensive medicine. That being said, I do know that when a couple of docs get together it’s as likely as not that the conversation will turn to malpractice eventually. I’ve also talked to several docs who have admitted that one of their reasons for working at the VA is that they don’t have to worry about malpractice. Both of those anecdotal data points lead me to suspect that defensive medicine is a bigger effect than the estimates.
    It’s also worth pointing out that when docs talk about “tort reform” they are talking about removing the arbitrariness and perceived unfairness from the system rather than establishing caps on “pain and suffering” awards or what have you. Most MDs have little clue about the meaning of the words “tort reform”.

13. J Bean, I am on your page, but I would like to know where you got your numbers for the last paragraph/line.
    I think it is very true that many on the left or progressive end have a blind eye for defensive medicine (although I do not think that there are many progressive physicians who are not very aware of the so-called “tort signal”). One major problem is that there have been some studies/estimates downplaying the cost of defensive medicine … and there is the major problem that it is impossible to reduce the decision to initiate a medical test or referral to just one single cause/motive incl. defensiveness. I think that we need new research, with a different approach, in this area.

14. I agree with pp. I started to write about the malpractice issue last night. I was recently included in a lawsuit (I think I’ve since been dropped from the suit because I hadn’t actually been involved with the patient for 4 years) which was a “delay in diagnosis” and “failure to refer to specialists in a timely manner” lawsuit. Those are two of the most common grounds for malpractice. In this case, the patient was diagnosed with lung cancer and is still alive 14 months later — meaning she was diagnosed early with an aggressive disease for which there is no known useful screening procedure and little in the way of treatment. (i.e. IMHO it’s a bogus lawsuit.) However, it seems likely that the physicians who are still included in the lawsuit will probably pass COPD patients on to the pulmonologists more quickly in the future. It’s certainly made me a more likely to order chest x-rays in my COPD patients mainly for CYA purposes.
    It’s popular on the lefty blogs to admire the VA and the European countries’ efficiency in medical care. However, it’s equally popular on lefty blogs to ignore the higher use of primary care physicians and reduced physician vulnerability to malpractice at the VA (the docs are federal employees and essentially un-sueable) and Europe (different cultural expectations and legal practices).
    It’s worth pointing out that 70-80% of U.S. physicians are specialists and 70-80% of European physicians are generalist/primary care physicians.

15. I agree that changing the payment system to favor cognitive codes versus procedural codes is a start.
    I think Deron misses one important problem when he says that training should be revamped to give primary care more scope of practice and that is the legal system.
    Most, if not all, of the primary care physicians in the country have the skills to handle more scope than they practice. The physicians assesment of mal-practice risk leads the physician to refer out to a specialist rather than handle the problem. It is very hard for a primary care physician to prove that he is as competent to handle a condition for which there is a specialist available (by definition of specialist). This leads to referring out the patient. Since there is a specialist of sub-specialist in just about every category we end up with a costly system with a need for heavy coordination.
    The low reimbursement rates also lead the primary care physician to refer out the problem. Getting $40, before overhead and expenses, make the $9/hour during residency very appealing.
    Everyone seems to under appreciate how much the legal system is the underlying structurer of medical profession. The costs of having a malpractice suit brought against them are very high (for many it means the end of their carreer as a physician). This means that physicians are rightly assessing that risk aversion is the correct path to take. This means primary care works in a triage position and only handles that which has low risk and refer out any conditions which risk associated with them.
    Specialists charge higher fees, not only for the “extra years of training” but also for being the risk taker on these conditions. The problem is that due to the way the reimbursment system is setup, primary care has to see more patients and refer out even the low risk conditions to specialists.
    This has caused a boom in earning for specialists. The reimbursment system has not adjusted downward to take into account that they are seeing alot of low risk patients.
    Malpractice carriers have adjusted for volume and risks better and should be used as an indicator for annualized reimbursement.

16. Good points by all! For the most part, I think we can all agree that a revamped primary care system would be beneficial.
    J Bean – You’ve highlighted the complexity of the issue. Maybe realigning the RVUs to shift compensation from specialists to PCPs is only the starting point. That would at least start making primary care a little more attractive from the financial standpoint. Then it seems we should look at the education/training aspects you mentioned to produce primary care candidates that can handle a broader scope of conditions.
    You also made the point about the mindset among all of us that favors specialist care. That will be a difficult one to tackle, but I agree it’s an issue. Maybe if we start producing solid GPs that are appropriately paid, we can reduce that mindset over time.
    Peter – I’m with you on the lifestyle/environmental issues. Our lifestyles have slowly changed over time to accommodate changes in our surroundings. It’s been gradual, so many seem to have taken things for granted. More and more processed foods have made their way into our diets because of the convenience factor. We don’t have time to exercise because there are too many other “priorities” in our lives. We can change all we want in terms of the delivery of our healthcare, but addressing the things you mentioned is really the most important issue of all.
    Mark – I’m keeping my fingers crossed that SGR, Medicare rates, and the RVU system are all addressed very soon. It’s a key piece of the reform puzzle.

17. Unfortunately in this country the consumer seems to have a strong preference for specialist care. I lurk on a diabetes forum and find it easy to tell the Brits from the Americans. One group refers to their treating docs as “my GP” and the other refers to their treating docs as “my endo”. Type II diabetes is not an exotic disease requiring specialist care. The same can be said about a wide variety of conditions. I see patients all the time who are seeing 3-4 specialists for assorted, minor, benign conditions. In the U.S., the primary care doc is frequently reduced to the role of triage which is a tremendous waste of training, time (see one doc, get all four conditions treated!), and money.
    I know that I harp on this point a lot, but in the U.S. all post-graduate (residency and fellowship) training is paid for by the federal and the state governments. We train too many specialists. We should simply reduce the number of specialist training slots available to produce more primary care doctors. At the same time we also need to strengthen outpatient medical education at the resident level to improve the quality of primary care and promote it as a desirable end to medical training rather than a necessary step in the pursuit of further specialized training. In many European countries there is often a two track training program. Access to specialist training requires further educational time spent in research projects prior to medical school graduation. In the U.S. there is very little impediment to specialized training. The American medical graduate can usually find a training slot in the specialty of his or her choice, spend 1-3 years (obviously a few spend considerably more time) and can easily make 2-4 times the income of a colleague who goes into primary care. A lot of incentive and little disincentive pushes the result in the obvious direction.

18. Investment in primary care won’t mean much unless we also change that which causes sickness; improper food, lack of exercise, poverty and environmental toxins. We must shift tax and polluting industry friendly regulations away from destructive practices. The save now/pay later mentality cannot be sustained.

19. In my opinion (and our firm’s analysis), nothing will happen in primary care until the SGR and Medicare reimbursement is addressed at the policy level. Hopefully the new (111th) Congress coming in January and the new Administration will work together to address this as issue #1.