An article in the Feb. 7, 2009 issue of the New York Times, “For I.B.M., Insurer Reopens Test of Rewarding Doctors for Healthy Patients” (www.nytimes.com) described a new way that insurers plan to make primary care doctors more effective, pay them more for their coordinating skills. The idea is to centralize all of a patient’s care through a central clearing house that is managed by the patient’s personal physician. This approach is supposed to cut down on unnecessary testing and consultations. But, to a large degree many family doctors already act as if they were running medical homes for their patients. It’s part of their professional duties. They set up appointments with consultants and provide follow- up care and do their best to order the necessary tests, coordinate nursing home and home health care.
Although the medical home is touted as innovative it is a resurrection of the “gate keeper” concept that insurers tried to get primary care doctors to sign on to in the early nineties. It failed then because most physicians felt that it burdened them with more work than they could handle, more responsibility than they should accept, and more pressure than they could bear. Doctors who accept the idea are supposed to get paid more for their “new” coordinating functions. But the danger is that primary care doctors will be deluged with more paper work than they can handle. Already paperwork consumes 20% or more of their time and on some days much more.
Increasingly, over the past few years patients are told by many health care providers to “see your primary care doctor” whenever irritating and time-consuming paper work has to be done. Once personal physicians are formally designated as the “medical home” base they will be inundated with more administrative work than imaginable. Not only will this subtract from the time they should be spending with patients but, any added income will have to be spent on ancillary staff to help with the added paper work.
As medical home doctors, as part of cost and quality control it is inevitable that every treatment they prescribe will be tracked by insurer’s electronic medical record systems to assure that doctors are following their prescribed guidelines. Doctors who do not or who are considered outliers will be penalized. Eventually doctors will succumb to insurers’ demands or suffer economic sanctions.
Guidelines have strong financial goals and they have strong potential to dehumanize the practice of medicine more than it is. Doctors may rationalize that by following guidelines they are providing good care but, once financial considerations are put into the equation, the doctor-patient bond becomes tainted and any physicians will be forced to put insurers’ profits ahead of patients’ needs.
Common sense and economic saving could be injected into medicine if a new contract could be entered into with the public. One that is more “clinical” and less “scientific” could significantly cut down on health costs without jeopardizing patient safety. For starters, are complete annual physicals really needed every year? How about the exhaustive batteries of tests we do, the results of which often are normal and often done for legal reasons or because the patient just wants them? It seems that every other CAT scan I do uncovers an “incidentaloma” that leads to more scans, consultations, and sometime biopsies, not to mention the time lost in ordering them and getting clearance from insurers and explain to patients why. Many patients suffer needless anxiety waiting for follow-up scans.
It seems that manufacturers of new medical tests and machines have an incentive to invent more of them because there always will be a ready market for them. Desirous of a competitive edge, physicians and hospitals, like patients are desirous of new technology even if the benefits are marginal. And of course there is always the legal imperative to do everything to avoid malpractice suits based on allegations of not having ordered the latest new-fangled test.
Public dialogue is woefully anemic in solving our health care system’s problems. Universal health care which is on our lawmakers’ minds won’t work unless a new contract is struck with patients. The process must be led by physicians and, not, as has been the case by economists and lawmakers. It must include tort reform and assessment of new technologies' unintended consequences including costs, diagnostic confusion and, any legal consequences that may arise for its non-use.
Ed Volpintesta MD
Saturday, February 14, 2009
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2 comments:
As president of SIMPD, the Society for Innovative Medical Practice Design, the professional society open to all concierge and other direct practice doctors I want to confirm that the reason health care is so fragmented and disrupted today is the lack of excellent primary care America once had. That fact in large part results from the devaluation of primary care and its extremely low pay status under the third party and Medicare dominated payment system we now suffer under
The concept of REAL "medical home" is a critical one. Every American needs one, a place they can access top notch primary care immediately and fully like one can access a concerned family member. And they need to buy that home directly, not with other people's money. When they do so the cost can be very low to the patient and the benefits very high to patient, primary care doctor and society.
The only payer willing and able to pay what a medical home will cost is the patient. Interest in concierge medicine is therefore rapidly growing. Starting with the first such practice about twelve years ago in Seattle and growing exponentially, there are now thousands of such practices in the USA, some are associated with franchises though most are independent. No mater what the government does, that is where the action will be in the future as our numbers grow from the current thousands to tens of thousands to hundreds of thousands.
Direct practice doctors and those who wish to adopt the direct practice model can join the society and get many benefits including up to 55% discounts on malpractice insurance, practice marketing help, national care networks and many other services. Our society is rapidly growing its membership. Direct practice doctors have much more time with their patients, make a better living, and virtually never get sued. That is why we get huge malpractice insurance discounts.
Patients can go to SIMPD's web site at http://www.simpd.org for information and to find such a doctor in their own community at the "find a physician" link. This is the ideal way for patients to get personalized, prompt, excellent primary medical care in a unhurried, pleasant setting. Money is actually saved on patient care in such practices because emergency room visits and hospitalizations are drastically reduced due to of the personalized, immediate, detailed care we deliver. The cost of concierge care, which averages about $150 per month, can be as low as $40 per month. This is affordable for most Americans, while the fragmented primary care most are now getting through employers or government third party interference in the doctor patient relationship is penny wise and pound foolish.
SIMPD believes most Americans can eventually be cared for in such direct "medical home" practices resulting in far better care. This will result in lower overall cost and a return of interest in primary care by students who now shun the field as undervalued, underpaid and undesirable compared with other medical specialties which for the same or lower levels of training and effort often pay double and tripple what primary care pays inside the insurance system.
If any of you have further interest please contact me through the SIMPD web site. I answer all emails through that site personally.
Thomas W. LaGrelius, MD, FAAFP President, SIMPD http://www.simpd.org 877-448-6009
Owner, SPFC Torrance, CA http://www.skyparkpfc.com
Thomas LaGrelius’ description of concierge practice and the medical home is not new to me. I applaud his efforts in searching for new ways to deliver primary care services. But isn’t there a concern that not everyone will be able to afford a medical home under his terms?
For instance, patients will have to pay their monthly fees to him and also continue paying for their regular health insurance as well. I say that because if they require catastrophic care they will need coverage for hospital care, expensive testing, and consultations.
I imagine there will always be a market for concierge practices but they will most likely thrive in communities that are affluent.
Ed Volpintesta MD
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