politics and practice based on mindfulness

Monday, April 13, 2009

Obama & healthcare part I: how to achieve "universal care"

I am a family physician who has been in primary care practice for over 14 years.  If you're a Obama supporter (like me) you're probably as pleased as I am that he is determined to extend healthcare coverage to all Americans.  But to achieve universal care, there are tougher challenges ahead than the obvious issues of enrollment.  

Based on what I'm seeing from day to day, we need to keep the adminstration focused on the following issues:

Shortage of primary care doctors.  MDs in my field are retiring faster than in previous times because of burnout from paperwork, and the constant struggle for documentation and pre-authorization.  Most medical students recognize this, and they are choosing not to enter the field.  They have large student loans, and are forced to choose more lucrative, procedure-oriented specialties.  No matter how common insurance coverage becomes under the new plan, there won't be universal care in the future if this trend continues.  

Routine use (and over-use) of specialty care.  Other countries where primary care is the main delivery system of healthcare have the same or better health in their citizens. We continue to be a country that expects specialty care, despite that this care is more expensive and may be more dangerous (because of more interventions that may lead to complications).

We have solutions, but it will probably take great political will to implement them:

Lighter loan repayment plans for students graduating in family practice would encourage more to enter the primary care fields.  Also, with a complete overhaul of the current reimbursement schedule, insurers should offer greater rewards for the health and wellness care delivered by primary care doctors. This will save the system even more money in the long run if we have a single-payer system. Current employer-based insurance coverages have no incentive to invest in the long-term, since employees switch jobs many times in their lifetime.

In case my post seems to be simply self-serving, here's a story to show the implications for the average patient.  One of my over-90 patients who is currently in care for coronary disease, has undergone cardiac catheterization TWICE in the past 6 months despite the fact that she and I have agreed on treatment with medicines, and not surgery or invasive stents.  The cardiologist has little incentive not to perform these tests since Medicare reimburses very well for them. 

In this situation, the cardiologist acted more like a highly paid plumber than a physician, in not looking at the entire situation and taking into account what is best for this elderly patient.

More examples of the over-use of specialists can be found in a recent New York Times article by Jane Brody: “More Isn’t Always Better in Coronary Care.” Surgical invasive management has been expanded without any data that these expensive interventions extend life for the majority of patients who receive them.

-- submitted by Dr. Deborah Campbell MD

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