News/Commentary

Doctors who work in certain large, multi-group specialty practices have unlocked the secrets of giving patients high-quality, comprehensive care at a total-per-person cost that is much less than what a patient in a small, independent practice gets, say two experts who wrote an Op-Ed article in The Washington Post’s June 6, 2009, edition.

There are many policy experts who can point to the stars of large group practices and find hard evidence of the benefits of the way they organize and deliver care.

The most famous examples are household names. Kaiser Permanente has its roots in a practice like the one described above, which was established a long time ago. The Mayo Clinic is that kind of practice on a grand scale. In between, in large cities, there are outstanding examples of this practice type and they usually have excellent patient outcomes.

However, there is one problem.

To be able to have a large, multi-group medical specialty practice, the practice has to have a large enough number of people living in its service area to become patients.

This is a perfect picture of why health care reform is so challenging. This is a big country and in the middle of this big country is a lot of land and not so many people living on that lot of land. We call these the “rurals.”

True, there are cities, like Chicago or Dallas, a good number of them, dotting the rurals. There are not, though, enough of them, close enough to people living further out, to make it possible for rural residents to rely upon them as their source of care, their medical homes.

The “rurals” have been a problem—-in the larger scheme of the nation and how it delivers care to patients—-since I was a newborn.

They still are. Much money, many foundations, countless think tanks, medical schools, schools of public health, government agencies at every level have thrown themselves into the rural issue. It is not that they have not been successful, many times, within the scope of what they set out to do. It is just that the “rurals” are so big, it is hard to make a dent in the problem.

Now, lest anyone think we are taking the easy problems first, the rurals also include every state in the South, a region with health statistics that are the poorest in the country. This, too, is a complex problem, the statistics resulting from a mix of poverty, race, culture, local economies and whether or not people earn their livings in a way that provides them with health insurance.

When you see the annual report, with map, on the health of the American people, the South is jet black—-meaning the disease rates for those states is the highest, or worst, of any in America. No other region comes close.

I grew up in the Southern  “rurals.” I know how little it has changed in  my lifetime and most of that change has not been to the good. Young people who see jobs elsewhere go, leaving small towns with fewer and fewer residents. That means even fewer doctors.

It is barely possible for these towns to recruit primary care doctors—-the family practice specialists, internists and pediatricians—-to work there. A group? That simply is not going to happen. These towns are lucky to have one or a handful. That’s it.

The experts who wrote the Post Op Ed piece are highly regarded. They identified the places where patients get the best care, the best outcomes clinically and the best outcomes per dollar. That takes them to these big, multi-specialty clinics where, without a doubt, the care is superior.

The question of how to deliver high-quality, cost-effective health care is so urgent, the search is for examples of what works so it can be duplicated.

In the meantime, the rurals keep on being the rurals, with no such group practices likely to be near the people who live there.

Enter the Obama administration, which hopes to attract medical students to practice there.

At the risk of sounding 100 years old, I have been through that, too. Back in the 1970s, there was a big push in medical education—and most definitely in state-supported medical schools—to find ways to make rural medicine attractive.  It is lonely being the only doctor in town or the only one practicing a specialty, such as surgery. Area Health Education Centers (AHEC), was a Johnson administration initiative to see if there were a way to give doctors in the rurals a support system, a way to stay connected to other physicians through these Centers. Results were hard to measure but the intangible benefits were apparent from the start. As programs go, this one went.

My point is not that we should not try.

My point is that we need to understand that these problems always with be with us. It is just plain hard to deliver quality health care, wherever you do it, with whatever resources you have, whatever your rank in your medical school class and to whomever you are caring for. These star multi-specialty clinic physicians work very hard to deliver what they deliver, despite the blessings of location, reputation and resources. Day in and out, the battle to keep quality high is just that. A battle.

Now, consider what it is like for the care-givers who do not have the resources, the gift of team-work and other benefits as they deliver care. Harder. Much, much harder.

If health care reform is built upon the conviction that there is only one “right” way to organize and deliver care, we have already lost. That group practice model can’t work in many places simply because of geography, simply because of where the patients are.

Somehow, if the group practice model as the experts above know it, is to be the “ideal,” then the “ideal” model needs to be expanded to create a virtual group practice for the “rurals,” one that delivers to them peers to talk to and work with and other tools to improve quality. In a way, that would be like the AHEC program but a constant source of information and support. Can that be done? I don’t know. I know that, or something like it, will have to be done if care standards are to be raised for every patient.

Read about how the Obama folks are going to try to help the rurals now.  It is the opposite of the “model” specialty clinic.

New York Times

“Calling a doctor on his cell? No waiting for an appointment? It’s the type of service that Dr. Batlle tries to offer to all of his 1,500 patients. “I prefer to keep them healthy than treat them when they are sick,” he says.

“The efforts of Dr. Batlle and other primary care physicians may get a boost at the federal level. The Obama administration is considering ways to persuade medical students to pursue careers in primary care by raising their pay, and is channeling them to work in underserved rural areas. And the White House has already set aside $2 billion for community health centers through the economic stimulus package.

“But more far-reaching health care reform remains an uncertainty, and in the interim a small but growing number of doctors are trying to take matters into their own hands.

” By stepping off the big-clinic treadmill, where doctors are sometimes asked to see a different patient every 15 minutes, Dr. Batlle has joined the vanguard of physicians trying to redefine health care. These doctors spend more time with patients, emphasize prevention and education to keep them healthy and can handle many medical problems without referrals to specialists.”

…”Exact numbers are hard to come by, but doctors involved in this movement, called “patient centered” practices, say its popularity is growing.”

Source: New York Times, June 6, 2009

Source: Washington Post, June 6, 2009