The Wonks Are Wrong

I’ve heard critics express the idea a thousand times in a thousand ways.

The idea goes like this:

The system is terrible. It is fragmented. It is inefficient. It is too costly. It relies too much on specialists. Patients with chronic disease see too many over-paid specialists who don’t talk to each other. What we need is more well-paid primary care practitioners. They will provide accessible, continuous, comprehensive, coordinated, connected-electronically, and patient-centered rather than specialist-centered, care.

The Shadow

The problem is between the idea and reality falls a shadow. Patients aren’t listening.

They prefer the choice and freedom of picking their own doctor. In many cases, this doctor is a specialist who treats their specific problem. Patients feel they have enough information to make their own decisions as to what physician to choose. The American public is specialist-oriented. This is why the typical Medicare patient with chronic disease sees 5 or 6 specialists a year, rather than going through a personal primary care doctor who directs their over-all care

The Problem Comes Home

This problem came home to me yesterday. I accompanied a patient to visit her primary care doctor. When her primary care physician diagnosed late-onset type 2 diabetes, she informed him, “ Please refer me to an endocrinologist who specializes in diabetes.”

He replied, “But I can handle your situation perfectly well. I have all the resources and knowledge needed to manage your illness , including a nutritionist and a team of other providers, to handle your diabetes.”

“No, “ she said, “ I want to see an endocrinologist, inside or outside your system.” She was not concerned about the “fragmentation” of the system.

The Dilemma

Therein lies the dilemma – whether patients chose to be handled by “systems of care,” and funneled through a primary care generalist within the system or to go directly to a specialist of their own choosing.

This is not a trivial matter. It stands in the way of widespread establishment of Primary-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs). And it will be a point of dispute between primary care physicians, specialists, and patients. Many patients feel they are perfectly capable of choosing what doctors to go to.

Patients are often unaware of background arguments about primary care doctors working proactively to keep patients healthy, coordinating patient care, achieving measurable better outcomes, and focusing on “whole patient care,” rather than specialists addressing specific illnesses, offering life-style procedural salvations and one-on-one solutions.

In choosing doctors, patients still prefer to think for themselves, rather than having others think for them.

If their decision involves “waste” for the system, so be it. One person’s idea of waste may not be reality-based.

50 replies »

  1. If people ask me, I tell them to go to a good PCP when they have a garden variety illness (such as type 2 DM), and a specialist when it’s something either more complicated or more rare. The PCP specializes in taking care of routine issues and will do a better job. That stuff tends to be boring to a specialist who would rather see something a PCP can’t handle. Good PCPs will also tell you when your issue is out of their range of expertise. So the trick is finding a good PCP and then using his/her expertise – that’s how to get the best outcomes at the least expense, in my experience.

  2. Cwells says:

    “Mr. Ogden, while I find this such a spirited debate, perhaps I was remiss in replying, as it appears to have been turned into a more personal conversation, rather than a general one”

    It’s the reflexive M.O. of some of the (untraceable) regular naysayers here. Insufficient to quibble with the contested merits, you gotta go all “you’re naive / totally ignorant / a ‘liberal’ / ‘Socialist’ / Moocher / out to enslave doctors, yadayadayada…”

    Tired stuff.

    • BobbyG why are you so hung up on having my home address and measurements? You have just about reached the point of being obsessive with your insistence on knowing what type of underwear I wear and sheets I sleep on. What does any of that have to do with the ideas debated here?

      You have an unhealthy infatuation with tracing people.

      • it wouldn’t have anything to do with the way people like you like to intimidate and bully people that disagree with you is it? Are you going to picket outside my house? Maybe you are going to start a letter writing campaign of clients and threaten them?

      • Oh, pul-EEEZE, Nate. No one’s gonna fall for that tired, comical red herring. It’s simply an observation about people who continually take ad hominem shots at others from behind an unlinked screen name. That’s all.

        I am directly accountable for everything I post. You could have my home address and phone number and a photo in all of about 3 seconds. I am completely transparent. You, and some of these other pejorative hosers, are not.

        End of debate. I am quite psychologically healthy, Dr. Ogden. Nice try. Nobody’s fooled.

        Amusing, but, let’s get back on topic, ‘eh? About how “The Wonks are Wrong” I refer you back to the first comment under Dr. Reece’s post.

        • so an unlinked screen name makes one untaceable? Your argument is having a linked screen name makes you accountable but requiring someone to go all the way to Linkin, facebook, myspace, or google search to find even more info then what your linked screen name provides is hiding from accountability?

          ad hominem attacks….would that be anything like discrediting the argument of someone that doesn’t have a linked screen name just becuase they don’t have a linked screen name and insinuating they are hiding from accountability, is that the ad hominem your referring to?

          Please keep talking Bobby, you do a far better job discrediting yoruself then I could ever do.

          • Keep missing the point.

            “discrediting the argument of someone” doesn’t require reflexively calling him/her “ignorant,” sheltered,” naive,” “liberal,” “socialist” (as if, in particular, the latter two appelations dispositvely refute someone’s policy viewpoint).

            Back on topic? Ever?

          • BTW- shall I go back and locate the comment wherein you accused me of being “racist”?

            Yeah, I’ve really been obsessed with personally hunting you down over that one.

            Get serious, bro’.

        • CODA:

          In fairness, Nate, I have to observe that YOU, at least come here frequently with tons of detail arguing your POV, unlike our other angry resident flamers.

  3. Sorry this is off topic, but I won’t waste time forwarding this comment to the prior post from days ago, and I think it has a little relevance here anyway:

    A colleague pointed out to me today that a prescription for an antidepressant med was rejected by the insurance company because they will not reimburse for an extended release formulation dosage, so the doctor must write for a shorter acting version. And yet, the insurer concluded, contraindicated mind you, to write for a dose that is a higher risk to cause seizures and thus not recommmended by the original pharmaceutical company that released it.

    So, if the doctor writes for the suggested dose and the patient has a negative outcome, who is negligent and culpable for the consequence? Are people going to continue to defend insurer and government intrusions into health care interventions when said supervision will be shielded by the very laws that allow these intrusions and disruptions into care?

    Yeah, these laws and financial management plans are so great and well intended, until what, they screw you, the advocate?

    Some people have the insight and vision of a mole. Just keep burrowing along until you hit a stationary object. Oops, didn’t realize it was a fox’s jaw!!!

    • “a prescription for an antidepressant med was rejected by the insurance company because they will not reimburse for an extended release formulation dosage”

      This is in fact largely the case.

      “Yeah, these laws and financial management plans are so great and well intended, until what, they screw you, the advocate?”

      Y’know your chronic “everyone-else-sux” anger is charming (what is your blood type? H2SO4?), but, precisely, what are YOUR proposed solutions? Precisely. Not the bumper sticker variety.

    • I don’t think its lost on anyone that the insurers still have most of the cards. And that won’t change until there is a viable option to take away the control they have over the health industry.

      • like self funding where 50%+ of all private insurance is not funded by an insurance company? And 50% of all care is funded by government, so what is this amazing power insurance companies have with their 25% market share?

        • Self funded care? Private insurance? I’m not sure wich you are talking about. 50% of all care is provided by the government? Are you referring to Federal or State? If Federal,are you referring to Medicare? Surely you are not suggesting seniors and Medicare recipients comprise 50% of the population. Or are you lumping Federal employees in there too, like congress, etc. Hey, now there’s cost savings. Let congress buy their own private insurance from their pet private insurers like they want the rest of the population to do, and while they’re at it, lets also turn their government pensions over to wall street like they want social seurity to be turned over to. Think that will happen?

          • Cwells, if you don’t know what any of those terms mean you should probably spend less time ranting about the evils of insurance companies and more time learning what your talking about.

          • Mr. Ogden, while I find this such a spirited debate, perhaps I was remiss in replying, as it appears to have been turned into a more personal conversation, rather than a general one. I will not respond to this subject again. I don’t feel this is the proper forum.
            C Wells MBA BS RN

          • insurance companies are evil and have to much control isn’t really debate, its more dogma that ignores the reality they represent a very small piece of the market and a meaningless percent of the cost.

            self funded refers to the 50% of businesses that don’t purchase insurance from an insurance company, they assume the risk themselves.

            Medicare and Medicaid with a sprinkle of VA account for roughly 1 trillion of the 2 trillion spent on healthcare. Again this is risk assume by someone other then insurance companies.

            In light of these facts I would ask which cards exactly is it that the insurance companies have?

            What control do they have over the health industry when the government tells them what they will cover, who they will cover, how they will receive claims, what format they will receive them in, what their EOB looks like and says, what their benefit books look like and say just to start. Is that really control?

    • what Rx are you referring to, give me the details and I’ll show you why they do it. The ER probably cost 10 times as much as the generic of the old version.

      While it sounds great that a new pill only needs to be taken once a day and thus the poor helpless members doesn’t need to remember to take it 2-3 times a day the difference in cost is not affordable. If we had to pay for the ER of everything there would be no generic Rx market everything would still be brand

  4. MD as HELL, I must oblige, so I have to ask how much money are you going to give the poor? I suspect not enough to pay for anything substantial.

    The bigger issue I have here is, why should care provided by an endocrinologist be more expensive than the same care provided by a primary care doc? Is it implied that specialists should be paid more for the same work? Why? I know this is the current status, but I think it should change.

    And I think patient-centered care means that patients decide where to go, when to go and if to go. Medical homes can help coordinate things and provide education/information, but I don’t think their job is to restrict informed patient choices. It’s supposed to be a home not a correctional facility….

    • “It’s supposed to be a home not a correctional facility”

      And not a care-obstructing “HMO” as originally envisioned by the Suits.

        • @MD as Hell: Are they “entitled” to have that money? How is a patient supposed to make an informed decision about whether or not to see a specialist? You say the poor will make that decision? Most of the poor can’t afford health care, unless they are lucky enough to qualify for Medicaid.

  5. If the patient was writing the check he would shop differently. The patient would try it with the PCP unless the anxiety of not going to the endocrinologist was powerful enough for the patient to value and pay for the specialist. Why should the system pony up the funds to assuage a patients irrational anxiety?

    This is the entire problem in a nutshell: Who determines value? Who holds the money? Who spends it and for what purpose? With ObamaCare and all other third-party systems, public of private, the money is spent either for political “profit” or actual “profit.

    The patient must control the money.

    Margalit will argue the poor have no money. I say just give them the money and let them shoose how to sped it. But no free care anywhere. No exceptions to the facts of life and the consequences of poor planning and lack of vision.

    Something has to remain an evolutionary force in this species.

  6. No good primary care doc should have any concerns if a patient chooses to receive care from a specialist (or vice versa). My practice is full of diabetics who hated the assembly line treatment they received from endocrinologists.

    However, if it comes down to financial incentives mandated by the ACOs who own the docs, expect everything to change (and not to the patient’s benefit).

  7. Aside from that, if the PCP and endochrinologist were in the same ACO, wouldn’t it be easier to manager her care effectively? The patient “doesn’t care if the endochrinologist was “inside or outside the system”. Refer her to one inside the system.

  8. To me it seems natural that you would want to see a specialist when first given a diagnosis like Type II diabetes.

    If I were the PCP I would have said “I agree, it would probably be comforting to consult with an endochrinologist at this stage to find out if there’s anything special about your specific case that I may not be aware of. However, if it turns out that you have generic Type II diabetes, I would strongly recommend that you come here for ongoing care, as managing this disease and keeping you healthy without costly intervention is what I ‘specialize’ in.”

    Of course I’d see a specialist when given a life-altering diagnosis like this. But I wouldn’t allow a specialist to manage the care going forward unless I had a crazy kind of Type II diabetes.

    Personally, I have very tricky sinuses. I often see my PCP first, but in some cases, I need to see the specialist because my sinus problems are sometimes too complicated for a PCP to be able to handle effectively. For other health issues I have that are much more standard, my PCP is perfectly adequate.

    This doesn’t forebode doom. What forebodes doom is the endochrinologist saying “Don’t let the PCP manage this, you really need a specialist” when in reality the person has a perfectly normal case of Type II diabetes that in fact is best managed by the PCP.

    • Completely agree. In my experience, the vast majority of patients actually prefer their PCPs over a specialist, especially with relatively common problems like type 2 diabetes because the PCP is the one doctor who knows them the best.

  9. I don’t like the bow tie, but Dr. Reece is on the mark.

    One could point out that not all patients are like this, but there definitely is a substantial fraction, and this fraction is larger in the US than in a lot of other (I would postulate most other western) countries. This has become a cultural phenomenon that cannot be reversed from one day to the next, and I believe (although I wasn’t really around at that time) that is in part why HMOs failed.

  10. I know this doesn’t fit with your implicit “All-Is-Lost” lament here, but:

    “The Robert Wood Johnson Foundation on Thursday launched Care About Your Care, a website to help consumers learn about healthcare quality and offer tips on being more-engaged patients.

    The site is part of a monthlong effort coordinated by the RWJF—with support from federal healthcare agencies—to boost public awareness of healthcare quality issues. On Sept. 15, TV host Dr. Mehmet Oz and Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation, will be featured at an event in Washington to spotlight the quality movement and show examples of how quality-focused changes are affecting patients and physicians.

    “Even though more information about healthcare quality is available than ever before, few people use that information to make decisions about their care or even ask doctors and nurses all the questions they have,” Lavizzo-Mourey said in a Care About Your Care news release…”


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