Physicians

Could a larger investment in primary care cure the health care system?

I’m going to go out on a big ol’ limb here by saying that 90 percent of our health care problems could be solved by rebuilding and refocusing our primary care delivery system.

It’s the issue most discussed issue in reform circles (aside from single-payer) and it makes perfect sense. Toyota has succeeded because it goes to great lengths to find the true source of quality issues. They have recognized that addressing root causes significantly limits efforts needed because you avoid treating secondary level problems that occur further down the line.

A highly trained, appropriately paid primary care physician with a focus on prevention, coordination and patient education could solve so many other problems. There are many preventable chronic illnesses out there driving up our costs.

Malpractice would be less of an issue because there would be less care
episodes, and particularly less intense care episodes. Coordination
would actually be easier to accomplish because there would be less need
for it due to a decreased need for specialist services.

And administrative
costs would go down because there would be fewer health care
transactions. The law of supply and demand would become more of a
factor because the decreased demand for services would have a greater
impact on physician and hospital costs, as well as drug costs.

EMR, PHR, HIT? Why are we designing elaborate systems when we don’t
even know what the ideal delivery system looks like? Technology cannot
make a bad company, service, or system great. It can only allow them to
do bad things faster.

Yes, I know I have over-simplified some things, but let’s not make this
more difficult than it needs to be. In the past I’ve spouted off about
how our problems are “multi-dimensional” and the solutions will have
“many facets.” Blah blah blah! Let’s get back to the days when the
physician-patient relationship was the center of the health care
universe, back before there were specialists and subspecialists to treat everything. I don’t need to
live to 120, because that might mean I need to work until I’m 115!

Ok, so let’s get started. Let’s reallocate the relative value units (RVU) reimbursement system to assign more
value to “cognitive” services, and prevention and coordination
activities, and away from procedures that only add value when
they’re medically necessary.

Let’s strategically
place midlevels in positions within physician practices, and allow them
to handle the primary care activities that don’t require the expertise
of a physician.

Finally, let’s step up as a citizenry, get off our duffs and exercise, forgo the trip to fast food joint, slow
down when we’re on the highways in a hurry to go nowhere, teach our
kids some responsibility, and stop and smell the roses every once in
awhile.

When the smoke clears from all of that, we can address the remaining 10 percent.

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laurelrbarHealth Insurance Guiderbarpp Recent comment authors
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rbar
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rbar

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?

laurel
Guest
laurel

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.… Read more »

Peter
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Peter

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

rbar
Guest
rbar

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… Read more »

Peter
Guest
Peter

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… Read more »

rbar
Guest
rbar

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… Read more »

J Bean
Guest
J Bean

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… Read more »

Peter
Guest
Peter

“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… Read more »

Health Insurance Guide
Guest

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.

Deron S.
Guest

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… Read more »

Peter
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Peter

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… Read more »

J Bean
Guest
J Bean

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… Read more »

rbar
Guest
rbar

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… Read more »

J Bean
Guest
J Bean

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… Read more »

pp
Guest
pp

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… Read more »