Thursday, June 11, 2009
Improving Access to Primary Care and Coordination of Complex Chronic Illness
In order to maintain income levels, they resort to many techniques. One, of course, is to see more patients per day but each for less and less time. This means they spend all too little time taking a through history or physical and instead send the patient off for expensive tests and X-rays or to specialists for referral. If a patient cannot get through to their PCP and instead goes to the ER for an urgent problem, the patient will probably spend hours there and the costs will be much more. The ER physician does not know the patient, does not have access to the old record and as a result feels obliged to obtain multiple tests and images to make the proper diagnosis. This is “nuts” – the person’s PCP might have been able to solve the problem quickly, with fewer or no tests. Better, quicker care for the patient and less expense for the insurer.
PCPs also try to increase income by arranging for tests to be done at their office like stress tests. A technician arrives with the equipment and does the test for which the PCP gets a fee. Are more tests done than truly necessary? Should these tests be done only in consultation with a cardiologist and under their supervision?
Something needs to be done to alleviate these problems. Somehow the PCP needs to have an incentive not to have too many patients and to spend the time needed with each patient. This means a higher per visit reimbursement. But it needs to come with incentives. PCPs receive about 5% of the medical care dollar but can and could greatly affect the other 95%. So there need to be techniques tried to allow and encourage the PCP to give good preventive care, counsel about important issues, meet their patients at the ER, use email and the phone more [neither are currently reimbursed] and coordinate care when the patients needs to be seen by a specialist or have a test or procedure. Coordination of care is especially important for the 5-15% of patients who have complex chronic illnesses and hence need a team of providers to give care. The “team” needs to actually function as a team and it will do so only if someone is orchestrating its work. Primary care physicians need to change from the long held practice of being interveners to being orchestrators, especially for their patients with chronic diseases. This will be a culture change but it will also require monetary incentives – it will not occur otherwise.
Praise for Dr Schimpff
The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.
-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).