Tuesday, July 06, 2004

From The Washington Post: Primary Loss A Doctor-Patient Mourns a Once-Key Health Care Bond
I'm on my fourth primary care physician in four years.

My first physician's practice dropped my managed care organization, feeling that it could not negotiate a rate adequate for the practice to survive. I was told to pick a new primary care provider from the organization's list. I'd barely met my chosen physician when, like so many others, my provider closed.

I was then offered the opportunity by my employer to choose a different health plan and a new primary care physician. This time I chose "point of service" coverage, which promised more provider choice. I met primary care physician number three. Three months later, I received a letter stating that she was turning her practice into a VIP program. As she shaved her practice from 3,000 to 200 patients, I could stick with her for an upfront annual fee of $1,500; she would still charge my insurance and I would still face co-pays and deductibles. Though reports indicate that this type of "boutique care" is growing and that it appeals to some, it struck me as excessively costly and exclusive.

That brought me to primary care provider number four. Meanwhile, as I bounced from one doctor to another, my children's pediatrician chose to leave practice, citing the pressure to provide "assembly line medicine" in the face of inadequate reimbursement, bureaucracy and rapidly increasing rates for malpractice insurance.

You might think that my bad luck was due to a lack of sophistication in negotiating health systems. However, I am a physician. As such, I've had the dubious distinction of having firsthand experience with limited primary care access twice over -- once as a consumer and again as a doctor.

Sounds like stories we have all heard before. The author then goes on:
When my elderly father was hospitalized two years ago with a ruptured appendix and a subsequent heart attack, he had a surgeon who checked his wound, a cardiologist who checked his heart and an infectious disease specialist who checked his blood and tissue cultures. The surgeons took out the appendix, leaving a large open wound, and took him off the blood thinners prescribed by his cardiologist. The cardiologist recommended tests of his heart and restarted blood thinners, which made his wound bleed.
When, around three weeks later (one day after he was moved out of intensive care), my father was stable enough to be sent home, he was handed a stack of prescriptions written by one specialist without a follow-up appointment or knowledge if there was a pharmacy open that could fill his prescriptions.
Who was integrating the excellent piecework care he was receiving? Who was checking on how he and his family were dealing with his complex medical problems? I was able to help somewhat, but I lived thousands miles away. He needed a primary care provider who would act as an integrator of information about each organ system and a communicator who could help him, his care team and his family understand his situation and anticipate the next steps.

This happens in hospitals all the time, even when there is a primary care physician involved with the patient. Such things happen with the "care by committee" that occurs in today's hospital. When confronted with a problem within their defined scope of practice but outside their "comfort zone" the thing to do is order a consultation. Then you have consultants ordering other consults and the care of the patient then spins out of control. Even when a physician has issues with the treatment ordered by a consultant, such as antibiotic choices by an infectious disease specialist, they are not likely to voice it openly or question it in the chart since the ID physician is "the specialist". The primary care physician is often under economic pressure to be in the office seeing patients and can't take the time to manage a complicated hospital inpatient. Thus the rise of hospitalists.
I'm sure to anger some with this, but it seems to me that the author wants the primary care physician to be more co-ordinator than provider of medical services:
Primary care has been defined by the Institute of Medicine, the advisory group of the National Academy of Sciences, 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." It is supposed to be the "medical home" -- the place where patients receive preventive care and help in negotiating our increasingly complex health care system. The primary care provider should know not just the condition of a patient's heart or kidneys, but the patient's overall health and how the patient functions in the context of family and community...... 36 million have no easy access to a medical caregiver because there are not doctors in their communities who are willing or able to care for them. In addition, among those that have a doctor, many report an erosion in primary care services.

In a large survey of adults published last year in the Annals of Internal Medicine, only 51 percent felt their primary care physician knew their medical history well. No more than that same razor-thin majority, according to lead author Dana Gelb Safran from Tufts University School of Medicine, felt their doctors knew much about their life circumstances.

Unfortunately, the current health insurance system doesn't pay extra for such things. Primary care is a volume business and social problems get the short shrift.

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