Primary Care VS Specializing - Cumulative Effect

[LabMonster]

The more I read, and the more I think about it, part of the problem with our health care system (HCS) is how we view and use specialists in this country.

Aside from the national health care plan debate, wouldn't increasing the number of primary care providers increase the overall health of this country and reduce the overall cost?

Primary care providers (PCP) who, and this is the stipulation hard to manage - are paid well as specialists in general medicine, can effectively manage a patient's care themselves and provide referrals upon reaching a diagnosis beyond their expertise, should be the single hub of medical care for any family seeking cost-effective medical care.

Under our current system, specialists can take any patient they want without referral (assuming insurance/payment is guaranteed), further, that specialist can provide that patient with primary care in addition to their our specialty.

But what if we used specialists truly as specialists, as consults/colleagues in secondary settings and staff in tertiary care care settings? The reduction in the number of primary care physicians has resulted in specialists taking some of that work over, but are they truly the best qualified for providing primary level care? One could argue that since a cardiologist as done some training as an internist before fellowship, that they are qualified as general practitioners. Conversely, a physician trained specifically in primary care cannot legally, ethically, or morally provide cardiology procedures. But is the cardiologist really suited to handling a patient's primary care needs?

The more a specialist sees patients for primary care purposes (and they do, because economically, it adds to their practice) the less time they have to pursue knowledge and research in their respective fields. In the US, the whole idea of having specialists is having "the best and brightest in their field." It seems we are missing the fact that the best and brightest could become primary care physicians and have a dramatic effect on healthcare in this country because they ARE the best and brightest in primary care!

In addition, if a new crop of primary care physicians could be cultivated, couldn't they focus more on community health and expand their practices (in general, not just a few) to house calls, free clinics, and off-hours clinics? In this way HC could be more available and more affordable to those who typically need more HC: low-income, elderly, uninsured or underinsured.

Whew. My thinking is this, we are focusing on simply how to pay for HC, without thinking about how our system is organized. Self-imposed organization of HC could potentially solve many financial problems inherent within the system.

Okay fingers are tired. Have at it

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[DrBowtie]

Yes having more PCP would increase the overall health.

Problem: PCP isn't a popular choice for med students.

 

[Shredder]

to me the question is what forces are preventing the market from taking care of the disbalance between PCPs and specialists. in other job markets this problem would solve itself. what regulations or incentives are awry

 

[DrBowtie]

to me the question is what forces are preventing the market from taking care of the disbalance between PCPs and specialists. in other job markets this problem would solve itself. what regulations or incentives are awry

Poor pay for FP. Also some just aren't interested in doing FP and since the "market" is good for a smart med student they can pick something else.

 

[LabMonster]

PCPs are not popular among pre-meds or med students because there is a heavy stigma attached, that is over long hours and low pay. But that need not be the case, indeed, GPs can have a tough time and deserve much more than some specialists.

If you look at market directives, you have to look at HC holistically, and realize that PCP generate the fewest dollars, while specialists generate the lion's share of medical dollars due to surgical procedures and specialist specific diagnostics. Obviously you would put you money on the guy bringing in 1,000,000 every month rather than the PCP bringing in 100,000. That in itself is a reckoning force, but dollars earned does not correlate to overall dollars spent. In other words, just because a specialist brings in more money due to their specialized practice, it does not guarantee long-tern fiscal stability within HC. The PCP does guarantee long term financial stability because patients with an involved PCP tend to be more compliant, have better outcomes, be more satisfied, and cost less than primary care relegated to specialists.

The short-term market is screwing long-term health and long-term socio-financial stability.

 

[humuhumu]

I don't know if this is really a good solution, but the vacuum in primary care seems to be getting filled by PAs, NPs, and DOs....

 

[LabMonster]

I don't know if this is really a good solution, but the vacuum in primary care seems to be getting filled by PAs, NPs, and DOs....

It's an excellent development, but not a solution. NPs, and PAs hold a great niche in primary care, but they can't replace a physician with training as a PCP. Don't get me wrong, I'm not insulting NPs or PAs - You guys effing rock (those that I've worked with) but a physician has a bigger knowledge base and more intense clinical program.

But PAs and NPs can often offer more "clinic time" and thus get a better primary care understanding of a patient than a physician - but this is due to billing procedures.....

 

[little_late_MD]

It's an excellent development, but not a solution. NPs, and PAs hold a great niche in primary care, but they can't replace a physician with training as a PCP. Don't get me wrong, I'm not insulting NPs or PAs - You guys effing rock (those that I've worked with) but a physician has a bigger knowledge base and more intense clinical program.

I think that it's interesting that for all the training doctors go through, the number of mistakes that are made in primary care are mind-blowing. I don't know if there have been any studies done that compare the number of errors among specialties, but who doesn't have an anecdote or four about some mistakes that their general practitioner made. I think that PCPs are just asked to have too wide a base of knowledge. Perhaps instead of less specialization, we need more, especially in the field of primary care.

 

[LabMonster]

I think that it's interesting that for all the training doctors go through, the number of mistakes that are made in primary care are mind-blowing. I don't know if there have been any studies done that compare the number of errors among specialties, but who doesn't have an anecdote or four about some mistakes that their general practitioner made. I think that PCPs are just asked to have too wide a base of knowledge. Perhaps instead of less specialization, we need more, especially in the field of primary care.

Now this is interesting. Anecdotes have no scientific value right? But, I understand what LLMD is saying here.

At age 13 I had a severe throat infection, but when I went to our PCP he swabbed my throat and sent me home - orders for fluids and NSAIDs. A day later my Mom called and was told the doctor had diagnosed me with m ono, and I should stay home for a week. So I stayed home, eased my sore throat with Jolly Ranchers, and played Final Fantasy (the Original) for 1 week. I did not have mono. I had a nasty virus that loved my throat. I was misdiagnosed and my care was mismanaged.

But what would have been different? Even then, the monospot test was available, and it should have been run. My negative Strep A culture was obvious, since only c18% of pharyngeal infections are caused by Strep A. The rest are viral etiologies...

Anyway. That PCP effed up. He sucked because he played the percentages and was wrong - but he likely saved other kids from viral pharyngitis, and allowed me to recover from mine (and I finished Final Fantasy).

So he was wrong, but in a dumb way, he was right. We've come along way in diagnostics and a misdiagnosis of mono would leave you laughed at.

We're better now, and I think the paradigm needs to be shifted toward primary care.

 

[mbadoc]

to me the question is what forces are preventing the market from taking care of the disbalance between PCPs and specialists. in other job markets this problem would solve itself. what regulations or incentives are awry

The problem is simple...In our current third party payer healthcare system, we reward high-technology, intensive treatments via high reimbursements and reward very little for low-technology, non-intensive, preventative care. The problem is high-technology, invasive care does not necessarily mean quality care or most effective/efficient care. We need to realign the economic incentives so that we reward physicians who provide QUALITY care and not just expensive care. Health outcomes need to be the benchmark for physician reimbursement rates and not just a fee schedule. It will require a lot of reform and will be a challenge to establish such a system, but it will be necessary.

 

[dabigv13]

Specialization is a huge reason for the increase of medical costs in the U.S. But the preferences of medical students isn't the only reason for the number of specialists, it's also the number of residency spots open. The market is correcting itself- some specialist residency spots are decreasing. But it will be a gradual and slow correction because a) patients PREFER specialist care (and they're the consumers) and b) doctors don't change specialties and can adjust better than other jobs to market "slowdowns" because they have higher pay and can reduce their workload and still support themselves.

EDIT: mbadoc is right too

 

[LabMonster]

The problem is simple...In our current third party payer healthcare system, we reward high-technology, intensive treatments via high reimbursements and reward very little for low-technology, non-intensive, preventative care. The problem is high-technology, invasive care does not necessarily mean quality care or most effective/efficient care. We need to realign the economic incentives so that we reward physicians who provide QUALITY care and not just expensive care. Health outcomes need to be the benchmark for physician reimbursement rates and not just a fee schedule. It will require a lot of reform and will be a challenge to establish such a system, but it will be necessary.

mbadoc - I know.

Anyway. How do we change the current system? This system is not screwed because we have sub-standard docs, or worse patients. The system is screwed because we are dealing with health as a luxury commodity.

 

[indo]

Now this is interesting. Anecdotes have no scientific value right? But, I understand what LLMD is saying here.

At age 13 I had a severe throat infection, but when I went to our PCP he swabbed my throat and sent me home - orders for fluids and NSAIDs. A day later my Mom called and was told the doctor had diagnosed me with m ono, and I should stay home for a week. So I stayed home, eased my sore throat with Jolly Ranchers, and played Final Fantasy (the Original) for 1 week. I did not have mono. I had a nasty virus that loved my throat. I was misdiagnosed and my care was mismanaged.

But what would have been different? Even then, the monospot test was available, and it should have been run. My negative Strep A culture was obvious, since only c18% of pharyngeal infections are caused by Strep A. The rest are viral etiologies...

Anyway. That PCP effed up. He sucked because he played the percentages and was wrong - but he likely saved other kids from viral pharyngitis, and allowed me to recover from mine (and I finished Final Fantasy).

So he was wrong, but in a dumb way, he was right. We've come along way in diagnostics and a misdiagnosis of mono would leave you laughed at.

We're better now, and I think the paradigm needs to be shifted toward primary care.

But, is there a treatment for a viral sore throat?

 

[LabMonster]

Sure.

Clear fluids and bed-rest.

Chicken soup. CS is the best remedy for what? Just about any viral illness - and nobody can figure it out. (But "we" think it tends to enhance seratonin channels and dopamine receptors)


Pedialyte rocks + sleep

 

[aamartin81]

There are a number of problems involved with the current healthcare system which cannot simplify down to being treated as a luxury expense.

Basic problems (short list):

People pay monthly premiums (much like auto insurance/life insurance), but go on to file claims at a frequency that would bankrupt other types of insurance.

Many people necessitate that healthcare is a right (I'm not here to argue whether this is correct or not). Should that right extend to those who knowingly subject their body to harmful substances (cigarettes, alcohol abuse, etc...)? Could you imagine an auto insurance company that would cover someone who went out and wrecked there car on purpose twice a month and proceeded to file a claim? If not, who becomes the moral authority on deciding who receives coverage and to what degree.

Some Consumers/Patients who pay low (relatively to the bills they accumulate) demand the newest technologies - Ie MRI's which cost upwards of $1000 - for an injury to their knee/shoulder that could be little more than a bruise (should the physician tell them no?).

There is a lack of standardization between insurance providers which leads to increasingly more administrative time spent of processing claims and checking benefits at the expense of time with patients.

Increasing costs in medical administration/malpractice coverage coupled with for-profit insurance companies with large degrees of leverage in setting reimbursement rates (which decrease each year) leads to physicians seaking higher paying areas (Ie specialities over primary care).

Technology which could decrease administrative overhead (Ie electronic medical records) do not provide the "first-mover advantage" associated with the integration of technology in other lines of business. Instead, those technologies offer (presently) independent operating platforms which do not communicate with one another - thus leading to more expense in administrative management.

If you are still reading, I'm impressed (I'm almost as tired of typing as I'm sure you are of reading). The fact of the matter is that with the growth of managed care, being a physician has become more and more of a business.

My idea for fixing the problem start with limiting the exposure insurance providers have to a patient's claims over a set period of time. As it stands, patients have no incentive to seak cost-efffective remedies. If you limit their benefits to a certain dollar amount over a five year period (for example), you could allow for the unanticipated catastrophic event/surgery while limiting the the use of many services (MRI for a knee bruise) to those that are willing to pay for them.

Another large component of fixing the healthcare system is the integration of standards of benefit/elegibility/claims among insurance providers.

I'd be intereseted to hear opinions,

Adam

 

[ablumoon]

Adam,

Wonderfully put. Your ideas sound pretty good to me, but it also seems as if patients who can't afford high-technology procedures are going to be discriminated against and feel that they aren't getting the "best care possible." With increased access to medical information, such as the internet, people know what options are out there and feel that it is their "right" to get the best care possible, regardless of how much money they have. I like the idea of capping benefits over the long-term, but I wonder if it may occur that patients who can't afford high-tech care, but need it, will not get it anyway. There also needs to be a way for patients who really do need certain procedures, to get them.

I do believe that there needs to be integration of standards among companies--but I wonder if the federal government would actually partake in this. I think one of the biggest problems with insurance companies is the cost of administrative overhead, which is 14% of the budget of many companies! I mean that is absolutely ridiculous. I understand that healthcare is a business, but considering the amount of money they have, 14% is a *%*& load.

For those who don't have insurance, who don't qualify for medicaid or work part-time and don't have insurance through their jobs, there needs to be at least a nation-wide preventive medicine plan so that they can have access to basic health care (like pap spears, basic check ups, immunizations, etc).

S

 

[aamartin81]

You bring up very valid points about access that will unfortunately have to be decided at one point or another (thankfully not by me). People talk about socialized medicine as an answer, but it presents it own problems. While everyone has equal "access" to procedures/testing, the waiting time becomes the new limitation. Consider the emergency bypass surgery in the US. The procedure can likely be scheduled and performed in 3 days or less in the US, while in Canada there is ~25 day wait to get to the cardiologist, then ~15 days till you can schedule surgery. Result: patient dies. Seems like a case of pick your poison. The reason I don't see socialized medicine occuring in the US is that lawmakers who currently have access to all the specialized care they desire will never give up that opportunity to stand in line behind a drug dealer who had a heart attack.

As for the cost of admininstration, I handle the administration for a physician and the time dedicated to insurance management is likely 20-30% of office hours (if not more).

I like the continued conversation...

Adam

 

[LizzyM]

I like the model of specialists who also provide primary care. Consider small town America. They need primary care providers and a small proportion of the patients also need/want the services of a specialist for a common chronic condition such as juvenile diabetes or arthritis. So a rheumatologist and an endocrinologist go into practice together taking any patient who needs primary care (after all, they did a 3 year residency in internal medicine and they are internists) and the community gets the extra benefit of having a "specialist" as well.

This is less feasible in large cities where everyone seems to be a specialist and no one wants to bother with primary care because it isn't very interesting, it takes a lot of time, and the reimbursement is puny.

 

[Shredder]

The problem is simple...In our current third party payer healthcare system, we reward high-technology, intensive treatments via high reimbursements and reward very little for low-technology, non-intensive, preventative care. The problem is high-technology, invasive care does not necessarily mean quality care or most effective/efficient care. We need to realign the economic incentives so that we reward physicians who provide QUALITY care and not just expensive care. Health outcomes need to be the benchmark for physician reimbursement rates and not just a fee schedule. It will require a lot of reform and will be a challenge to establish such a system, but it will be necessary.

first i think the burden of health insurance should be lifted from employers and placed onto individuals and private insurance, with the appropriate tax reforms to reduce friction. and then, in my eyes, the solution always boils down to opening the floodgates to allow tons of docs to enter the market. there will be unemployment, but none of us will have to worry since that need only apply to the crappy docs. all of the primary care, underserved, and rural woes will vanish. keeping track of outcomes and making information readily available will be important, but consumer reports does it so a doc reports could do it as well. so far there are some companies like doc reports, but none have garnered widespread support or market share like consumer reports has with cars, or cnet for electronics and such

 

[benelswick]

. keeping track of outcomes and making information readily available will be important, but consumer reports does it so a doc reports could do it as well. so far there are some companies like doc reports, but none have garnered widespread support or market share like consumer reports has with cars, or cnet for electronics and such

I think your ideas are good, but, quantifying an outcome for human beings with chronic problems seems problematic. My mother who's an N.P. sees the elderly people of Bradenton, Florida. Most of her patients are old and broken down and their care involves negotiating simultaneous chronic conditions and visits to her clinic are often social/psychological in nature....which makes me start to wonder, how are outcomes tracked and rated in general?

 

[LizzyM]

in my eyes, the solution always boils down to opening the floodgates to allow tons of docs to enter the market. there will be unemployment, but none of us will have to worry since that need only apply to the crappy docs.

Crappy docs means crappy care for those unfortunate enough to be subjected to their ministrations. That's no way to improve access or reduce costs.

Also, moving health insurance away from employer-provided programs means that every person will be applying for insurance as an individual and you get into difficulties with those who are a financial liability. If my employer has 3,000 employees, the insurance company accepts that some of them have a family history of cancer, some have kids with chronic illnesses, etc. We pool the risk and it's not so bad. If each of us was subject to underwriting based on health history, some people would be uninsurable or insurable only at astronomical rates (and hence uninsured or under-insured).

There was a time (in the 80s) when florists and hairdressers who bought insurance individually (because they were self-employed in their own shops) just couldn't buy insurance (the price went through the roof) because of the assumption that they were at high risk for HIV. Is that what we want for everyone (not just the self-employed)?

 

[Shredder]

Crappy docs means crappy care for those unfortunate enough to be subjected to their ministrations. That's no way to improve access or reduce costs.

idealism is a noble goal but in reality this is how all other sectors of the economy work, be they goods or services. substandard docs are better than nothing, and even if not that, a choice between substandard and nothing is better than no choice. a flood of docs would provide care for the "underserved" and such, and competition would solve many of the problems in healthcare such as rising costs. the only other way to reduce cost is govt interference instead of a market solution, and throughout history govt has never solved anything or at least not better than the market has. the AMA and AAMC intentionally restrict the number of docs at the expense of society and to their own benefit. its the same way taxi drivers push for the licensing of their jobs to limit new entry into the field. the quality of docs has an artificially set lower bound, thus the saying "all med schools are good", which isnt said about any other type of professional school or profession

why dont employers pool risks for car insurance, life insurance, and home insurance? health insurance should be as actuarial as other forms of insurance, it would give people an incentive to take care of themselves. its only proper that the ppl who pose more risk pay more to avert that increased risk. well i think insurance is a subject of high importance in healthcare and merits detailed analysis and discussion

 

[CTSballer11]

If you keep track of outcomes and rate doctors accordingly, many docs will only take up the easiest of all cases. Thus the complex patients may be turned away from 99% of doctors. Now if these same patients were worth more points and could really boost a docs rankings if treated correctly then more docs may take them on but I think we are on a slippery slope if we rank doctors like this. If you want better doctors to go into primary care then the PAC docs need to be paid more then they are now. Money and lifestyle does wonders for a specialties competetiveness, Ie: Derm, optho, rads. I think the major problem is that docs in general do not come together and lobby like they should in congress. They are to busy working and are continuing to get ripped off by insurance companies. Congress should make billing insurance companies less of a hastle and they should raise the rates medicare reimburses docs. I think we need some real savy people to sit down for a few months (kind of like the founding fathers when they drafted the constitution) and rebuild our healthcare system. Tough task but I would make health insurance more accessible to the people without cutting physicians salaries. Not sure how to do it but I am sure that it can be done. Malpractice reform is a must and I think if frivalous suits are thrown out this could save the healthcare industry a ton of money. just some thoughts.

 

[mbadoc]

idealism is a noble goal but in reality this is how all other sectors of the economy work, be they goods or services. substandard docs are better than nothing, and even if not that, a choice between substandard and nothing is better than no choice. a flood of docs would provide care for the "underserved" and such, and competition would solve many of the problems in healthcare such as rising costs. the only other way to reduce cost is govt interference instead of a market solution, and throughout history govt has never solved anything or at least not better than the market has. the AMA and AAMC intentionally restrict the number of docs at the expense of society and to their own benefit. its the same way taxi drivers push for the licensing of their jobs to limit new entry into the field. the quality of docs has an artificially set lower bound, thus the saying "all med schools are good", which isnt said about any other type of professional school or profession

why dont employers pool risks for car insurance, life insurance, and home insurance? health insurance should be as actuarial as other forms of insurance, it would give people an incentive to take care of themselves. its only proper that the ppl who pose more risk pay more to avert that increased risk. well i think insurance is a subject of high importance in healthcare and merits detailed analysis and discussion

Under the current third party payer system, having more docs in the system would just allow the insurance companies to slash reimbursements to physicians even more as physicians would have even less bargaining power. In order for your market solution to work, it would require a transition back to fee-for-service where doctors could charge whatever they wanted for a procedure or check up.

On a practical basis, the reason why they need to "artificially" limit the number of physicians is because 1) it cost a tremendous amount of society's resources to train a physician 2) the best and brightest would not enter medicine if they knew that they had to train for 7 to 12 years, incur massive amounts of debt, and find out at age 35 that due to market forces, they may be unemployed facing massive amounts of debt and then having to declare bankruptcy and live on welfare. Lawyers and Business people don't face this because they do not have to go through such long periods of training and there job skills are more transferable.

On the first point, the training of a medical student/resident is very much like an apprenticeship. More than any other profession, it requires one-on-one training where the training physician must literally guide one student at a time. If medical school classes and residency programs were to balloon in size, who would train these future doctors? The cost to society of training all of these students would be tremendous as the time that Doctors have to heal people would be taken away with all of the teaching and training.

 

[Shredder]

1) it cost a tremendous amount of society's resources to train a physician

you make some valid points, but i have to raise qualms with this. doesnt it cost society's resources to train any field of study? but dont med students pay for that cost, especially those who attend private schools? i dont see the need for any charity to be going on. sure med school profs teach and guide students, but for a heavy price. and residents work their tails off for paltry sums, much lower than the value of the services they provide. med students make a voluntary decision to undertake the time and debt required to become docs, just like other careers. med school takes more but thats why the compensation is higher in the end.

its true though that the ~10 yrs required to train docs makes forecasting difficult, whether its by central planners or individuals. still that shouldnt matter, its like investing in a 10 yr project and not being certain of the outcome. and ppl will do that provided the risk/reward works out favorably

concerning docs losing bargaining power with insurance--that should only happen to the docs on the lower end of the bell curve. hotshot docs should still have power. right now the bell curve for docs is too clustered around the middle, there should be a wider spread representing a greater total number of docs. just like in engineering, law, etc, which never face crises or problems or shortages

the investment analogy is a key point

 

[DropkickMurphy]

Sure.

Clear fluids and bed-rest.

Chicken soup. CS is the best remedy for what? Just about any viral illness - and nobody can figure it out. (But "we" think it tends to enhance seratonin channels and dopamine receptors)


Pedialyte rocks + sleep

There's also evidence that suggests dexamethasone may be an useful adjunctive therapy in pharyngitis.

 

[dajimmers]

its only proper that the ppl who pose more risk pay more to avert that increased risk.

I find this idea interesting, sensible, but potentially very dubious. People who inherit genetic diseases aren't to blame for their increased risk, and should their parents be blamed for having kids? How do you determine if one's alcoholism is "their fault" or "their genes' fault?" Genetic linkage exists for nearly everthing but infectious disease (and even then, your MHC repertoire, etc. somewhat determines susceptibility). Is it an individual, or the society they are raised in, that determines their decision to participate in health-risky situations?

On a related note, should Social Worth play any part? Usually the answer is no, as who can really decide who is more worthy of survival? But, is it OK to state that the elderly should receive mostly cheap paliative care, when heart surgery *could* extend their life, and that this more expensive surgery should be saved for younger people w/ longer lifespans? What about death-row inmates, or terminal cancer patients?

I think an answer is to, instead of impose financial restrictions on individuals for their "poor" decisions, create a societal ideal of health and wellness that doesn't exist in this society. I'm being idealist, as I have no idea how to do this, but modelling societies like Japan would be good. Here, people have ADHD, and listen to the "newest findings" -Atkins, Trans-fats, but forget the previous 500 lessons for the new one. Only one bit of health at a time. Hopefully, if public health lessons can be taught in school and to families and communities, people will learn the preventative, money-conscious decisions necessary to help control costs.

 

[Shredder]

People who inherit genetic diseases

i knew this would come up and im not sure how to deal with it. then again genetics are linked to many more attributes than just health--intelligence, weight, body composition, life expectancy, smoking, drinking, recklessness, aggression...the issue of genetics and insurance is a doozy. i still think money is the best way to incentivize people to good health, and it should be thought of in that way rather than punishing people for bad health. nobody really cares right now what advice docs give them or the public sector gives them, theres little reason for them to follow it. their health of course, but most ppl are too short sighted to think about that--lotto tickets or tax breaks or something would be more effective to whip them into shape

 

[WildcatMD]

i knew this would come up and im not sure how to deal with it. then again genetics are linked to many more attributes than just health--intelligence, weight, body composition, life expectancy, smoking, drinking, recklessness, aggression...the issue of genetics and insurance is a doozy. i still think money is the best way to incentivize people to good health, and it should be thought of in that way rather than punishing people for bad health. nobody really cares right now what advice docs give them or the public sector gives them, theres little reason for them to follow it. their health of course, but most ppl are too short sighted to think about that--lotto tickets or tax breaks or something would be more effective to whip them into shape

I agree, money is the only way to change behavior

 

[dajimmers]

OK, I will agree that money is probably the only way to (quickly) change behavior...

So, do you think this "cost for behavior" should be based on tax bracket? If so, I could be more willing to accept it- not that I think the rich should have to pay more for everything, but I would want the poor to be able to go to the doctor and get a necessary treatment without fear they'll lose their house, but perhaps with the fear they'll have to eat at home once more than normal. I realize setting this cost scale will be incredibly difficult, and viewed as unfair by many, but if can be worked out to cost you something you'd rather not pay, but could afford to if you needed to, it just might work.

I much prefer individual rationing vs. doctor or insurance-based rationing, though often the knowledge of the doctor can be used to help the individual make rationing decisions.

 

[Minion677]

wow.. a lot of topics are discussed here. i dont know where to start.

specialists are acting less and less like primary care doctors now as a result of MCO's. you need to go to a "gate keeper" first and then he/she will refer you to the specialist. you cant go directly. this has effectively limited costs, but the problem is the incentive for the PCP to not refer you in a borderline case to save money.

what needs to be done is to implement some sort of universal coverage system where every person is REQUIRED by law to have health insurance. this could either be:
1. Health insurance from the government - only basic coverage and a few options - deductibles and copays - subsidies for the poor and elderly who CANNOT pay by themselves
2. Purchasing private health insurace like we do now
You could be able to get insurance coverage from work or individually, whichever way you want. This will not cause prices to go through the roof for the unhealthy as LizzyM was saying because the private insurances rates will be influenced greatly by the government rates (like it is by medicare now). As a backup, the unhealthy could get government insurance and pay less money. Or, we could require that private insurance doesnt turn down patients and that they cannot set exorbitant prices in the marketplace.

We need to limit options on the governments health insurance because we want to weed out the people who can pay for insurance themselves. We want to set the coverage level at a point where those who have enough money will pay on their own for the private insurance.

aamartin81's points on limiting overhead, increased standardization, and electronic medical records are spot on. that will definitely put some money back into the system.

by mandating health insurance, the poor will have increased access to it. granted, they will have limited access to doctors and procedures. however this will probably create an influx of PCP's into low income areas and a decrease in specialists, as PCPs can profit from handling their basic procedures.

 

[mustangsally65]

I thought I would bump this up. go primary care!

I hope to become a family medicine physician. More people need to go into this field.

 

[Shredder]

I hope to become a family medicine physician. More people need to go into this field.

whats in it for them to lead them to that choice

 

[dilated]

whats in it for them to lead them to that choice

Even more than that, being a PCP just isn't appealing to a lot of people. Even if specialists and PCPs got equal pay I wouldn't do it - when I shadowed a FP, the fact that he knew most of his patients and their histories by heart was nice, the fact that like half of the visits were for people with a cold or sore throat that wanted antibiotics wasn't. A big part of being a PCP is being the "gatekeeper" to medicine and you have to have a certain interest in doing that.

 

[DrBowtie]

Even more than that, being a PCP just isn't appealing to a lot of people. Even if specialists and PCPs got equal pay I wouldn't do it - when I shadowed a FP, the fact that he knew most of his patients and their histories by heart was nice, the fact that like half of the visits were for people with a cold or sore throat that wanted antibiotics wasn't. A big part of being a PCP is being the "gatekeeper" to medicine and you have to have a certain interest in doing that.

Agree.

 

[mustangsally65]

whats in it for them to lead them to that choice

I don't know about other people, but it makes me happy.

Knowing my patients by name, taking care of their whole families, having a role in preventing common diseases. I don't know why it appeals to me so much, but it does. My family doc is my hero.

 

[LizzyM]

when I shadowed a FP, the fact that he knew most of his patients and their histories by heart was nice, the fact that like half of the visits were for people with a cold or sore throat that wanted antibiotics wasn't.

I was a person witha sore throat. I wanted antibiotics or something that would make me feel better (I couldn't speak, could barely swallow saliva). I could tell that the doc was going to tell me that antibiotics are not a good idea for viral infections. Then he looked in my mouth. I had an abcessed tonsil. I hope that he didn't go home and say, "I saw someone today with a sore throat who wanted antibiotics -- what a bore!"

Do you want to be a doc because there are many intellectual challenges and one gets to use a lot of high tech equipment or do you want to be a doc who provides diagnosis, treatment and education to people who are hurting?

We need both. Pre-meds need to know themselves and find their place in the world.

 

[dilated]

I was a person witha sore throat. I wanted antibiotics or something that would make me feel better (I couldn't speak, could barely swallow saliva). I could tell that the doc was going to tell me that antibiotics are not a good idea for viral infections. Then he looked in my mouth. I had an abcessed tonsil. I hope that he didn't go home and say, "I saw someone today with a sore throat who wanted antibiotics -- what a bore!"

He probably didn't. But he was OK with examining the 5 or 10 or 20 that didn't have abcessed tonsils or a serious, treatable problem before he got to you, which would make him the right kind of person to become a PCP. Many others would find that frustrating or tedious. I'm just saying that the imbalance between specialist and PCP is not due solely to salary - it takes a certain mindset to enjoy primary care and I'm not sure that that mindset makes up a much larger percentage of future physicians than already go into primary care.

 

[LizzyM]

A very interesting thing happened in 1993-4. ( I realize that most of you are too young to remember this or didn't care too much about medicine at the time). Hillary became the czarina of health care and great plans were made. Medical schools held conferences and dedicated grand rounds to discussions of health care policy and the changes that were about to happen. PCP were going to be in great demand and specialist far less "special". The Match in '93 and '94 turned on a dime in comparison to '91-'92. Suddenly, everyone wanted to be a PCP. I was stunned that this huge ship changed course so suddenly. There has been a gradual shift back to the pre-90s way of life but even a whiff of financial incentive to pursue primary care will make it seem more desirable to some students.

 

[chef_NU]

idealism is a noble goal but in reality this is how all other sectors of the economy work, be they goods or services. substandard docs are better than nothing, and even if not that, a choice between substandard and nothing is better than no choice. a flood of docs would provide care for the "underserved" and such, and competition would solve many of the problems in healthcare such as rising costs. the only other way to reduce cost is govt interference instead of a market solution, and throughout history govt has never solved anything or at least not better than the market has. the AMA and AAMC intentionally restrict the number of docs at the expense of society and to their own benefit. its the same way taxi drivers push for the licensing of their jobs to limit new entry into the field. the quality of docs has an artificially set lower bound, thus the saying "all med schools are good", which isnt said about any other type of professional school or profession

why dont employers pool risks for car insurance, life insurance, and home insurance? health insurance should be as actuarial as other forms of insurance, it would give people an incentive to take care of themselves. its only proper that the ppl who pose more risk pay more to avert that increased risk. well i think insurance is a subject of high importance in healthcare and merits detailed analysis and discussion

I completely agree with Shredder. Medical insurance should be tailored to fit individual risks in order to provide incentives for healthy lifestyle by shifting insurance contracting away from employers and toward individuals. In this way, people will see much more of the real cost of the care that they demand and thus will be forced to think twice when considering asking for an "MRI for a bruised knee". I also think that false advertising claims need to be prosecuted much more strongly against big Pharma, especially with the amount of DTC advertising to consumers these days. WE NEED a strong FDA, which, as Shredder was saying; they should be the consumer reports of health care. If people realize that expensive procedures don't do much for health outcomes, they won't be asking for them. However, this only works if they have to foot (at least part) of the bill. Same principle applies to any type of commodity. People wouldn't go out and buy Bentleys just because they were expensive if they were of the same quality as a honda accord.

The moral of the story: people do not "deserve" the best possible care. You deserve what you can pay for. Consumers need to shop around for the best bang for their buck: i.e. the best private insurance plan with the best health outcomes they can afford.

 

[mshheaddoc]

you make some valid points, but i have to raise qualms with this. doesnt it cost society's resources to train any field of study? but dont med students pay for that cost, especially those who attend private schools? i dont see the need for any charity to be going on. sure med school profs teach and guide students, but for a heavy price. and residents work their tails off for paltry sums, much lower than the value of the services they provide. med students make a voluntary decision to undertake the time and debt required to become docs, just like other careers. med school takes more but thats why the compensation is higher in the end.

its true though that the ~10 yrs required to train docs makes forecasting difficult, whether its by central planners or individuals. still that shouldnt matter, its like investing in a 10 yr project and not being certain of the outcome. and ppl will do that provided the risk/reward works out favorably

concerning docs losing bargaining power with insurance--that should only happen to the docs on the lower end of the bell curve. hotshot docs should still have power. right now the bell curve for docs is too clustered around the middle, there should be a wider spread representing a greater total number of docs. just like in engineering, law, etc, which never face crises or problems or shortages

the investment analogy is a key point

Med students don't pay for residencies; medicare, VA, and medicaid funds them (well 100,000 spots)

Also I tried to find stats on the total amount of GP but I'm being lazy right now and got frustrated. But something like 35% of all Allopaths and 50% of osteopaths go into FP.

http://www.graham-center.org/x467.xml has some inforamtion on the waning population of FP. Although I have to question if this is a main source of our health care malaise.

 

[mshheaddoc]

I completely agree with Shredder. Medical insurance should be tailored to fit individual risks in order to provide incentives for healthy lifestyle by shifting insurance contracting away from employers and toward individuals. In this way, people will see much more of the real cost of the care that they demand and thus will be forced to think twice when considering asking for an "MRI for a bruised knee". I also think that false advertising claims need to be prosecuted much more strongly against big Pharma, especially with the amount of DTC advertising to consumers these days. WE NEED a strong FDA, which, as Shredder was saying; they should be the consumer reports of health care. If people realize that expensive procedures don't do much for health outcomes, they won't be asking for them. However, this only works if they have to foot (at least part) of the bill. Same principle applies to any type of commodity. People wouldn't go out and buy Bentleys just because they were expensive if they were of the same quality as a honda accord.

The moral of the story: people do not "deserve" the best possible care. You deserve what you can pay for. Consumers need to shop around for the best bang for their buck: i.e. the best private insurance plan with the best health outcomes they can afford.

In a perfect world medical care would be tailored to a person but trying to implement that in a world that has had the employer and government supported care for half a century is alot easier said than done. This has been tossed around for awhile but how does one implement this? Also ... is it fair?

To play devils advocate ... don't all humans deserve care? Who's to say that b/c you can't afford a transplant you should die? I don't really agree with your last statement.

 

[Uncle_Tbag]

Shopping around is not usually realistic. The only people who are cursed with having to shop around are the self-employed. On the other side are the more fortunate who can afford to pay a grand a month or more to cover their family.

There are too many benefits to group policies through an employer to abandon this model. Some people want a more free-market system in medicine, I think this is a good example of that at work. You buy in bulk, you get a much better deal. This way, I get good coverage for me and the wife for 70 a month instead of 500.

 

[Uncle_Tbag]

To play devils advocate ... don't all humans deserve care? Who's to say that b/c you can't afford a transplant you should die? I don't really agree with your last statement.

As doctors, or aspiring doctors, I'd hope most of us would say that yes, all humans deserve health-care on at least some level. I don't mean to say that all docs should be forced to accept all pts regarless of circumstance, but that we should have an innate sense of duty to be part of a medical safety net. That we will donate part of our time to free clinics, that we will work for free on pts who need it the most.

 

[odrade1]

to provide incentives for healthy lifestyle by shifting insurance contracting away from employers and toward individuals. In this way, people will see much more of the real cost of the care that they demand and thus will be forced to think twice when considering asking for an "MRI for a bruised knee".

Financial incentives are essential to making a change in healthcare. However, I tend to believe that both patients and physicians need incentives to make more efficient uses of medical resources and treatments. In my state, unless you have a salaried position at a public hospital, you are paid based on the number and dollar values of the procedures that you perform, and what % of collections are made from those procedures. Paitents must shoulder more of the short-term costs of procedures (why take a visit without an MRI if a visit with an MRI makes the doctor happy and provides the patient with the feeling that "something is being done", while costing the same as the visit without the MRI?), while being protected from the financial devistation of medical catastrophes. The way physicians are being reimbursed has to be changed (in what way, I have no idea) to remove or at least diminish the incentives to run additional tests or to practive defensive medicine (see JAMA's recent article on defensive medical practices and tort legislation).

WE NEED a strong FDA, which, as Shredder was saying; they should be the consumer reports of health care. If people realize that expensive procedures don't do much for health outcomes, they won't be asking for them.

I tend to see this as dangerous for two reasons:
1)laypeople do not usually have the time or abiltiy to find and process the large amounts of information required to determine which treatment is appropriate. (Isn't that the role of the professional; (i.e., the doctor?!)
2)The consumer reports of healthcare idea is dangerous because it changes the focus of physicians, and not necessarily for the better. Treating people who are less sick, and who have fewer complications is both less intellecually difficult (easier) & more likely to get you positive outcomes (and so higher success rates). If I got graded on how much I charged for services and how many of my patients had desirable outcomes, I would find it hard not to begin resenting the sicker and more elderly patients that came to me, or the patients with psychosocial factors that reduce their abilities to comply with the treatment plan. Yet all of these people desperately need care. Also, frankly, the idea of designing measures (like consumer reports) to allow laypeople (the kind who vote to let townspeople re-write science curricula, and who trust Oprah & Tom Cruise's views on physicial & mental health issues) to decide what specialist and what treatment is best for them is quite terrifying. A huge part of the PCP job is educating patients and assisting/guiding the patient in reaching decsisions about her health.

I have noticed that some of the posters are advocating a view of healthcare as business. Of course it would be naive to believe that business is not a fundamental force shaping healthcare; however, I think that it is dangerous for physicians to treat this aspect of healthcare as essential to how we should define the patient-doctor relationship:
(Many) People pay for heathcare, but it is not a commodity that can be described or shopped for in the same way that a television or automobile can be.
Education and healthcare are two areas that are being undermined by focusing too hard on the consumer aspects of students and patients.
A shopper for a television can be characterized as a consumer of electronics, and that description can capture 90-100% of the nature of what it means to be a shopper-for-televisions.
A patient/student can also be characterized as a consumer/customer, but that description fails to capture much that is important about what it means to be a patient or a student.

The moral of the story: people do not "deserve" the best possible care. You deserve what you can pay for. Consumers need to shop around for the best bang for their buck: i.e. the best private insurance plan with the best health outcomes they can afford.

I personally agree that not everyone is entitled to "heroic" healthcare. However, I believe that anyone drawing breath in this country is due basic medical care (the kind that a PCP can render from his/her office), common prescriptions, and pallative care. We could serve the health of this country far better by redirecting resources from extreme medicine & heroic healthcare efforts toward providing those in the bottom 20-30% of our socioeconomic ladder with regular visits to PCPs, health education, and basic care. Unless we were to spend 50% of the GDP on healthcare, we would never be able to provide every American with "the best possible care," and frankly, I don't think that is the best use of 50% of this country's GDP.

I've really enjoyed reading everyone's posts on this thread! It has been both stimulating and rewarding to see your views.

 

[Shredder]

That we will donate part of our time to free clinics, that we will work for free on pts who need it the most.

free ERs have put many hospitals out of business. even if docs volunteer their time, there are more costs involved in healthcare than just docs salaries, and those costs have to be absorbed somewhere. free anything is a good idea in theory but not in practice--it only works on a small scale, on a large scale free goods/services put far too much strain on systems, including the healthcare system. chefNU, i actually think the FDA should be done away with and shifted to the private sector--ive brought it up in prior threads, check out www.fdareview.org, its an interesting proposition

of course med students dont pay for residencies. regardless of whos paying, they still create more value than what they are reimbursed for, so that cant be counted as a cost to society

even a whiff of financial incentive to pursue primary care will make it seem more desirable to some students.

that is always the case in markets--the number of students who deem it desirable will be proportional to the financial incentive. if there is truly a need for primary caregivers, ppl need to put the dollars to it to solve that shortage. griping wont cut it, nobody wants to hear that. if they dont have the dollars (underserved folk), theyre in hot water, realistically.

idea: open a lot more DO schools. it would do wonders for the primary care market. say...theres business potential in that, if only i were 10 years older i could pursue it

 

[Uncle_Tbag]

free ERs have put many hospitals out of business. even if docs volunteer their time, there are more costs involved in healthcare than just docs salaries, and those costs have to be absorbed somewhere. free anything is a good idea in theory but not in practice--it only works on a small scale, on a large scale free goods/services put far too much strain on systems, including the healthcare system. chefNU, i actually think the FDA should be done away with and shifted to the private sector--ive brought it up in prior threads, check out www.fdareview.org, its an interesting proposition

Are there any studies that show how many times a free ER has put a hospital out of business? Not saying this doesn't happen, only that I'm not aware of any data.

If we look at primary care, non procedural, prevention, etc, I was saying that I hope most doctors would feel some duty to treat people who can't pay. Emergent care visits are a completely diff issue. Which I might add would be greatly reduced if more free access to pcps was available (or if people knew that most docs will help them for free if they explain their financial proplems).

 

[LizzyM]

I hope Shredder volunteers his opinions at every med school interview. It will make the adcoms' job that much easier.

 

[Saluki]

Shredder- Helpful hint- you're supposed to either not care about the money or pretend you don't care about the money...

 

[Shredder]

I hope Shredder volunteers his opinions at every med school interview. It will make the adcoms' job that much easier.

i know you me and my opinions, but i think i raise valid and relatively well articulated points that are relevant to the medical community. i see problems in healthcare, and id like to solve them some day. but i know that human nature is for people to act in their self interest, and keeping this in mind is the best way to construct solutions to problems IMHO. i think idealism is good, but it cant be the ideology used to make policies. problems need to be solved based on what is and how people are, not on what things and people should be. all of the pretense only hurts the healthcare system, and thats why i refuse to partake in it. business is incredibly efficient, while healthcare is quite inefficient; to me that says something, namely that healthcare should actually be treated more like business and not less. and things would work out better for everyone, i believe. for all the "diversity" med schools tout, there sure isnt a whole lot of diversity of thought. a good doc is a good doc, intentions are really not anyones business

plus, i never volunteer anything, theyd have to pay me for my opinions startup consulting business--shredders opinions, inc?

Dr GeddyLee, good read here that addresses the point perfectly http://www.hschange.com/CONTENT/312/#brief1
another: http://maillists.uci.edu/mailman/public/calaaem/2004-October/000413.html
the concept of "free" just doesnt work in practice