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"Who" not "How": The Real First Step in Health Care Reform
Primary care docs are becoming an endangered species. Here’s how to save them.

Kevin Kelleher, MD
Medical Progress Today
July 31, 2008

America's ongoing health care debate revolves around the problem of the uninsured: who they are and how to get them coverage. But this debate, while important, is fundamentally shortsighted. As Massachusetts is discovering now with its ambitious mandate for individual coverage, moving hundreds of thousands of people into an overburdened health care system leaves people with insurance, but no access to doctors.

And having health insurance without access to doctors is like having a car without the key to run it: you’re not going to get anywhere you really need to go. Instead, health care reform must start by reinvigorating the patient–physician relationship, which is the key to better access, better health, and lower costs.

Patients with one or more chronic diseases like heart disease, diabetes, and cancer account for the lion's share of U.S. health care spending. The future of health care lies in better management—and even prevention—of these expensive, often devastating diseases. But this future will only become a reality if we can offer patients coordinated preventive care and disease management in a thoughtful, knowledgeable manner, based on in–depth training. Luckily, this is exactly what primary care practitioners are trained to do.

Research has repeatedly shown that primary care providers are best positioned to help patients with chronic illness manage their conditions. For example, patients with diabetes often also struggle with obesity, high cholesterol, and poor circulation—putting them at risk for heart attacks and strokes, arthritis, and even blindness. Often, these patients are shuttled back and forth to various specialists, where care becomes fragmented, leading to repetitive testing, potentially dangerous drug interactions, and confused patients.

Ideally, primary care physicians should act as the "home base" for these patients by directing and coordinating care with patients, specialists and nurses, thereby avoiding repetitive tests and potentially dangerous drug interactions. Most importantly, they can develop personal relationships with patients that help keep them focused on improving their overall health through prevention and wellness programs.

Data reported by Dr. Barbara Starfield from the Johns Hopkins Bloomberg School of Public Health has demonstrated that healthcare systems centered on primary care providers are efficient, efficacious and cost-effective. For example, a 1996 study demonstrated that care episodes that began with visits to an individual's primary care clinician, as opposed to other sources of care, were associated with a 53% reduction in overall expenditures.

More recently, a 2007 article reported that a greater supply of primary care physicians in communities was associated with improved health outcomes, including all–cause, cancer, heart disease, stroke, and infant mortality; low birth weight; life expectancy; and self–rated health.

Sadly, primary care physicians, like Rodney Dangerfield, often get little respect, and are seen as less competent than "specialists" like cardiologists. The reality is that they are board certified specialists in their own right, and no other type of physician has the depth of knowledge or training to handle the multiple challenges of primary care—prescribing and managing multiple medications for diabetes and heart disease, discussing weight loss strategies, reviewing herbal and vitamin supplements, treating depression and eczema, and delivering an Influenza vaccination—often for the same patient in a single visit.

Unfortunately, as demand for quality primary care (Specialists in Family Medicine, Pediatrics, or Internal Medicine) is increasing, supply is decreasing. Since 1997, there has been a greater than 50% drop in the number of U.S. medical school graduates entering family practice; and only 20% of internal medicine residency graduates remain in primary care.

As the old adage goes, you get what you pay for. Over the past 10 years, Medicare payments for primary care have either declined or remained stagnant in the face of rising inflation—forcing primary care docs to shoehorn more patient visits into each day simply to cover practice overhead. Private insurers have eagerly followed Medicare rates; in fact they have often further reduced payments through various payment withhold tactics such as "bundling services" and "mutually exclusive" disallowances.

Currently, a thirty minute specialist procedure typically pays three to ten times as much as a thirty minute primary care office visit that addresses complicated health issues or preventive care. (Today, as a result of consolidation in the US healthcare industry, over 65% of privately insured patients are covered by just three companies, further reducing physicians' and patients' options.)

Practicing primary care doctors must typically keep daily visit volume very high (25 to 40 per day is common) just to stay financially solvent. Add to this the multiple hours per week required to fight claim denials, request authorizations for procedures, and redundantly document proof of medical necessity, and you have a recipe for frustration and physician burn-out.

In response, overworked and underpaid primary care physicians have reduced the number of services offered at their offices, increased subspecialist referrals for problems they could have managed had they more time, turned to high volume, single problem based visits, dropped inpatient work, or even opted for early retirement. Studies suggest that 20% - 40% of primary care doctors over the age 50 plan to retire early or reduce their practice in the next few years.

As bad as it is now, it will get worse soon. In ten years, approximately 35% of the population will be over age 50, and 1 in 5 will be over 65. The demand for quality preventive care, disease screening and chronic care management will increase dramatically, but the doctors just won’t be there to provide it.

The first step in returning sanity to American health care must be to decrease the need for volume–based primary care by increasing reimbursement for personalized quality care, thereby fostering the creation of a true "medical home". By increasing reimbursements, doctors gain the ability to spend more time with their patients to assess problems and concerns, discuss how lifestyle choices affect patient's risk of disease, and to reinforce the value of routine screening and prevention measures. Compensation should reward cognition, quality, and outcomes based on best standards and evolving science, not just rote procedures and quantity.

Remuneration must be based not only on actual visits, but on services associated with coordination of care, including management of issues outside the office setting, remote monitoring of clinical data, and communications with subspecialists. Physicians who distinguish themselves by efficiently achieving measurable and continuous quality standards should be further rewarded, as this produces cost savings and drives innovation for the system as a whole. Along side of these changes, medical schools must embrace programs to encourage the brightest and best medical students to choose primary care as a lifelong profession.

Fundamental changes in payment systems, tax structure, and tort reform will all be needed to support patient-centered care. Public and private insurers must also support health information technology in all physician offices, regardless of size; HIT should be founded on the principles of data portability, privacy, and ease of communication between physicians and patients. Finally, primary care physicians must begin a public education campaign, starting with patients and moving up to policy makers, to convey that national health care reform must begin with primary care reform.

The days of a trusted primary care doctor, who can talk compassionately with you about your diabetes or cancer diagnosis, as well as your child’s chicken pox or the need for their polio vaccination, are numbered. If changes are not swiftly and effectively implemented over the next decade, patients' best advocate for comprehensive care will become extinct.

Kevin Kelleher, M.D. is a board certified Family Physician who has practiced in the Northern Virginia area since 1996. Dr. Kelleher received his Medical Degree form the State University of New York at Buffalo and completed his residency at Franklin Square Hospital in Baltimore where he served as Chief Resident. Dr. Kelleher is involved in local community and corporate health education through various talks on health related topics. Locally, he works with medical students as an Assistant Clinical Instructor for GWU Department of Medicine. He has spoken widely on subjects including migraine management, smoking cessation, and health care reform.

He is co–founder of Executive Healthcare Services in Reston, Virginia, a retainer–style ("concierge") primary care office, started in 2004, which offers an innovative model of proactive, convenient and coordinated primary care for individuals, families and companies. He continues to own and manage a traditional family practice office, Generations Family Practice, also in Reston, VA. In 2005, Dr. Kelleher was ranked by Washingtonian Magazine as one of D.C.’s "Top Doctors".

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