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.

Tuesday, July 28, 2009

On the front lines of medicine

You've probably heard in the news lately that the role of primary care physicians (or primary care clinicians, which includes advanced nurse practitioners who can treat patients independently in many states) will be emphasized more in the health care system of the future. In the 1990s, the heyday of health maintenance organizations (HMOs), these physicians often functioned as "gatekeepers," among other things, determining if it was necessary for a patient to see a specialist for his or her medical problem. Some physicians had employment contracts that actually paid them more money to prevent patients from accessing specialty care - an uncomfortable (if not unethical) role that led to a popular backlash against, and eventual decline of HMOs as a means for controlling skyrocketing health care costs.

The Institute of Medicine has defined primary care as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." That's quite a mouthful! But who counts as a primary care physician, and why are these particular doctors so important?

Family physicians provide comprehensive primary care to patients of all ages; about 1 in 3 family doctors routinely delivers babies. General internists provide primary care for non-pregnant adults, and pediatricians provide care to infants and children through late adolescence (variously defined as 18 or 21 years of age). To complicate matters, many generally healthy female patients rely on their obstetrician-gynecologist (OB-GYN) for primary care, and a few patients with complex medical conditions, such as insulin-dependent diabetes and acquired immune deficiency syndrome (AIDS) may obtain primary care from specialists, such as endocrinologists and infectious disease physicians.

Collectively, primary care physicians are the "docs in the trenches," laboring on the front lines of medicine to diagnose and treat most common acute and chronic health conditions. But for a number of reasons (which I'll get to in a later posting), fewer medical students are deciding to pursue careers in primary care each year, and that's a big problem - not only for the cost of health care, but the quality of health care too. Stay tuned for why this is.

Friday, July 24, 2009

Where do you get your health care information?

If you have a friend or relative who's a doctor or other healthcare professional, you probably ask that person. (I remember getting questions as early as my first semester of medical school, when I was completely unequipped to respond to the simplest of questions, such as what to take for a common cold - though even fully qualified physicians often prescribe unnecessary antibiotics in this situation, as ER physician Zachary Meisel explains.)

Perhaps the most consulted source of clinical information online is the venerable WebMD. But there are other sites that are nearly as good, including, sponsored by the American Academy of Family Physicians. These websites are becoming increasingly sophisticated, often featuring podcasts and other interactive features in addition to traditional, static educational handouts.

So who or what is your most trusted source of information when you or a friend or relative falls ill? Your family doctor? Your internist? The paramedic you sometimes shoot pool with on Friday nights? Or an "alternative" health provider such as a chiropractor or acupuncturist? I plan to discuss complementary and alternative medicine in depth in a future posting, but for now I'd like to hear from you.

Welcome to my blog

I've started this Blog as a medium for sharing my thoughts on health and health care. Obviously, health is a personal issue, but these days health care is a very public issue subject to heated debate, especially in my home town of Washington, DC. There's a lot of talk about how the plans currently being debated will "ration" health care, as if rationing is inherently a bad thing. But that view would be a reasonable one if you believed that health care isn't already rationed - which it is. Just lost your job and can't afford COBRA? No health care for you! Have a pre-existing condition? Then pay your own way. Can't afford the copay for that procedure? That's rationing too. And the inherent problem with our current "non-system" of care is that it's, well, irrational, as Peter Singer describes eloquently in a recent article in the New York Times Magazine.

Politicians like to talk about the health care "safety net," consisting of clinics who care for the uninsured or uninsurable (e.g. undocumented immigrants). The heroic efforts of clinicians and staff who run these clinics, often for low pay and exceptionally long hours, do indeed make a difference and save lives. But for every patient who manages to make it to a free or low-cost clinic, there are 3 more who end up in an emergency room, often with diseases that are preventable with routine, relatively low-cost visits to the doctor when well. For a quick primer on the value of prevention in health care, see Pauline Chen's NYT column from yesterday.

That's all for now. I plan to post to this blog at least once per week, so please check back (or sign up to follow new posts) if you'd like to hear more.