News/Commentary

A  New York Times-CBS poll showed:

• Eighty-five percent of respondents said the health care system needed to be “fundamentally changed or rebuilt.”
• Seventy-seven percent of respondents are “somewhat” or “very satisfied” with their own health care.

• Most Americans would be willing to pay higher taxes so that everyone could have health insurance.
• Most Americans believe the government, not the private sector, would do a better job of holding down costs.
• America’s path to reform is not as straight ahead as these numbers suggest. The poll also found great unease about more government involvement in care as it affects the economy and the quality of care available to the individual patient.

Reform and Re-form…They Have to Go Together…Right Now, We Do Not Have Enough Primary Care Doctors to Re-form Health Care

We have to be able to pay for the health care we want. Off go the bean-counters, cutting here, negotiating there, creating a reform plan which on paper looks as if it is manageable. Plenty hard enough.

That is the paper plan. That is the plan that does not actually involve humans, care-givers and patients.

However, there must be—forgive the health care-speak here—-health care services delivery system re-form, which is not the same thing as the health care services reimbursement system reform.

Together, reform and re-form would be a bold effort to provide the medical care we as a nation agree that we need to be healthy and that we will will pay for.

We have to be able to have enough primary care doctors to make any reform plan become reality for America’s ill, injured, disabled and dying. It also is true that we need the right proportion of specialists, those who can skillfully manage progressive diseases which afflict or kill us in large numbers: heart care, diabetes care and cancer care, just to name those at the top of the list. We already are seeing some shortages in general oncology (cancer). However, producing specialists has not been our challenge. For patient care to work, there needs to be an agreed-upon ratio of generalists to assorted specialists nationally and, at least, regionally, if people are to get good health care.

When Washingtonians Are Starting to See Longer Wait Times and Closed Practices, Heaven Help the Rest of the U.S.

The larger problem is the lack of primary care doctors. Even in the Washington, D.C., region, which long has been labeled “over-doctored” given the ratio of physicians to patients, there are documented waiting times for patients to get into primary care practices or to be seen.

That ought to tell you a lot. This  region has been a laughing-stock among medical utilization experts, whose basic measure is doctors per 1000 patients. We are lousy with doctors, they have said for 25 years. Maybe not any more. What about you? What happens when you call for an appointment—-assuming you have a primary care doctor? If you don’t, start your search today.

(The utilization review experts track which patients use what type of doctors how often and more…much, much more. An example: How many women use their ob-gyns as primary care doctors for years after the birth of their only or last child.)

Simply stated, “access to care” problems refer to: (1) none, or too few, doctors for the population to be cared for or (2) to the length of time patients must wait for appointments when they do have doctors.

If patients in the nation’s capitol area are having access problems, then who won’t?

Access to care is step one. If you do not have access, nothing happens. No safety. No quality.

After access to care, we worry about safety and quality—-two separate but related issues.  (Hang in here. You need to know if these terms are not already familiar to you.)  Safety issues, first, focus on “never” events, the ones which, under no circumstances, should ever happen. Operating on the wrong body part is one example. We will spare you others. Quality, however, is far more subtle and vexing. America has begun a new quality movement. The nation has a lot of work to do here.

Each of these issues areas have their own experts. These issues are so complex, one must spend years learning what the numbers are, and those numbers really mean once analyzed closely, to see what’s really going on in, say, patient safety. They can’t afford a minute to pay attention to access.

The same is true for the access experts. God, let us just find a way to get enough doctors in the right places.Then we can worry about the rest. There are big areas of the U.S. which are classified “under-served.” Enough said.

In reform speak, these  areas of expertise are called “silos.” One set of experts in one silo focuses on one problem. The silos stand alone. How do we intelligently combine what they know and make that knowledge into a health care system for our people, place and time?

How Do We Get Enough Primary Care Doctors? Plan 12+ Years Per Doctor, Starting Today….

It takes 11 or 12 years to produce a primary care physician, give or take. How many years did it take for that one student to get through college because he or she had to work too? Does this future M.D. want to practice general internal medicine, but also wants to have a sub-specialty, such as cardiology? All of those take more time.

A scheming mother of a marriageable-age child should be selling cupcakes, or jewelry if need be, to put the future son or daughter-in-law through medical school—-with the understanding that that student would swear to go into primary care. The payoff for mother? Primary care for the rest of said scheming mother’s life.

There already are not enough internists, family practice specialists and emergency room physicians—-who have been forced into serving as de facto primary care doctors after hours. This should not be happening but it is. Emergency rooms are the place where all the gaps and failures of the system meet up. Go to one. You will see for yourself. Sore throats and strokes. Influenza patients coughing all over each other, as white-faced pneumonia patients arrive by ambulance. Every time there is a primary care shortage in any area or region, the ER staff sees anybody and everybody—-whether they are “emergency” patients or not.

There is another group of primary care physicians no one is even talking about: geriatricians. These physicians usually are board-certified in internal medicine and geriatric medicine. Their visits with patients take longer because they have many problems and may have limitations that slow down a visit—-hearing problems, cognitive declines, chronic pain, just to name common ones.

These doctors are paid less than primary care doctors who are paid less than specialists.

It actually costs a physician money to become board-certified in geriatrics. Why do they do it? They have aging patients and know they need a different kind of care. A geriatrician is a different breed, a physician wise enough to know time and attention are the best prevention tools for the common disasters that led to bad ends for their frail patients. The fall which could have been prevented, the fall which led to a broken hip, the broken hip which is the beginning of the end for so many parents, grand-parents or great-grand-parents.

There is a shift going on but people don’t have a name for it yet. Health care has to change from a piece-work approach to a value approach. Right now, we pay best for that which provides provable immediate benefits: surgical specialty care, for example. Cut it out. Take an image. Show us. Money follows.

A value approach looks at what range of prevention and early intervention (treatment) gives the patients the greatest benefits? What interventions work best when a patient’s disease advances despite everyone’s best efforts? (Diseases do tend to win in the end.) We should pay for those at least as well as we do the immediate-benefit medical care.

Health Care Reform and Re-form…and Those Who Have Deal-Breaker Demands

One enemy of reform and re-form are single-issue advocates or opponents, the ones who say, if you don’t have my ___ in the bill, it’s a deal breaker. You won’t get my vote.

That’s lobbying and jockeying for position.

But the truth is one of our biggest problems—-this shortage of primary care physicians—-is something even money cannot buy our way out of.

The issue of delivering primary care to Americans is not a deal-breaker, it is the deal-maker.

Without enough primary care physicians—-and intermediate steps to help those still practicing—-no plan really can work.

It is one minute to midnight, in legislative terms.

It is one minute to midnight. Where is your primary care doctor? Who will be your primary care doctor when your current one retires?

New York Times

…”The poll (NYT-CBS) found that most Americans would be willing to pay higher taxes so everyone could have health insurance and that they said the government could do a better job of holding down health-care costs than the private sector.

“Yet the survey also revealed considerable unease about the impact of heightened government involvement, on both the economy and the quality of the respondents’ own medical care. While 85 percent of respondents said the health care system needed to be fundamentally changed or completely rebuilt, 77 percent said they were very or somewhat satisfied with the quality of their own care.

“That paradox was skillfully exploited by opponents of the last failed attempt at overhauling the health system, during former President Bill Clinton’s first term. Sixteen years later, it underscores the tricky task facing lawmakers and President Obama as they try to address the health system’s substantial problems without igniting fears that people could lose what they like.”

Source: New York Times, June 2o, 2009