Wednesday, July 29, 2009

Lowering costs and improving quality of care

In my last post, I suggested that having fewer primary care doctors compared to specialists was a serious problem for U.S. health care. This may seem counterintuitive. Primary care physicians have a broad range of skills, but most specialists spend more years in training and know their particular area of expertise inside and out. You may wonder what would be wrong with going to see a specialist every time you had a health problem - for example, an orthopedic doctor for back pain or a cardiologist for chest pain? There are two very good reasons: cost and quality of care.

Simply put, there are powerful monetary incentives for specialists to do more to patients, and for primary care to do less. President Obama recently took some flak for suggesting that U.S. doctors' medical decisions are driven by economic incentives rather than what is best for the patient. In cases when the correct course of action is absolutely clear, I would agree with the many physicians who were outraged by Obama's comment. However, most of the time medical decisions aren't black and white - and it's in that wide "gray zone" where money comes into play. The more tests and procedures a specialist performs, the more money he or she earns. At a primary care office visit, on the other hand, payment maxes out quickly - so that there is essentially no difference between treating, say, 5 versus 10 medical problems, and writing more prescriptions or making more referrals doesn't have any effect on the practice's bottom line.

As a result, places with more procedural specialists have significantly higher health care costs (with the same or worse health outcomes) than places with fewer specialists, as Atul Gawande reported recently in the New Yorker. In fact, U.S. counties with more primary care physicians per capita have lower death rates, which some speculate has to do with specialists ordering additional procedures that are unnecessary (because they are not indicated for the patient's problem, or performed more often than guidelines recommend) and carry their own health risks. For example, Alex Krist and colleagues found that gastroenterologists in Washington, DC and Virginia recommended repeat colonoscopy (a screening test for colon and rectal cancer) at shorter intervals than necessary more than 60 percent of the time. They estimated that if this pattern of excessive procedures was similar throughout the country, it would cost an extra $3.4 billion and lead to more than 14,000 serious complications, including 142 deaths.

The bottom line? More primary care relative to specialists is not only good for the country's health, it's good for your health. So the next time you need to see a doctor, visit a family physician or general internist first. And tell your representative or Senator to make improving primary care access an essential part of health reform. As medical blogger KevinMD pointed out earlier this month in an address at the National Press Club, it does no good to give everyone health insurance if there aren't enough primary care doctors in the U.S. to care for them.

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