Thursday, October 13, 2011

Primary Care Physicians Can Greatly Reduce The Costs Of Care, Especially For Chronic Diseases

In an earlier post I described the problem of excessive and inappropriate drug prescribing when a patient with multiple chronic illnesses did not have good care coordination by a single primary care physician. In this post I will relate the story of a lady who had an excellent primary care physician but the communication system broke down when she went elsewhere for a single visit. In her case the problem was the recommendation of an inappropriate medical technology for her chronic condition.

Ellen is an elderly lady who had been going to the same primary care physician (PCP) for over twenty years. On nearly every visit she said that she felt “tired.” Repeated history and exam revealed no cause nor did logical tests such as those for anemia or hypothyroidism. She then developed syncopal episodes – times she would black out and fall to the floor, once bruising her head when she fell against the stove, and then waking up in a few minutes. Evaluation showed that she had intermittent episodes of bradycardia, or very slow heart rate, resulting in the drop attacks. In consultation with a cardiologist, it was decided to insert a single lead pacemaker. The pacemaker senses the electrical action in the heart and when the rate drops below a set level, it immediately begins to send out an electrical stimulus – on demand - to the heart muscle so that it will contract at a normal rate. The pacemaker is expensive and the procedure to place it is expensive as well. But it worked perfectly and she no longer had the attacks that were not only scary and medically dangerous but seriously impacting her quality of life. A good return on investment.

A few months later during a visit to her daughter, she went to that daughter’s internist for an unrelated reason; he urged her to see a cardiologist colleague. Both the internist and the new cardiologist heard the usual complaint of “being tired” and assumed it related to her cardiac status. This cardiologist in turn recommended that she needed a “dual lead” pacemaker instead of the single lead one she had. [It has been found that having more than one lead can sometimes improve the heart’s output for very carefully selected patients with heart failure.] When the PCP much later received the cardiologist’s mailed consult report, he disagreed, noting she did not have heart failure, just syncopal attacks – an electrical not a mechanical problem in her heart. Further, the current pacemaker was only needed about 10% of the time meaning that her heart beat at a normal rate at least 90% time, so the pacemaker was not even active most of the day. This lady did not need the proposed new, even more highly expensive pacemaker. No pacemaker, no procedure, no risk of insertion, no risk of post operative infection or bleeding. A lot of money could be saved and the patient could be spared a straight forward yet somewhat risky procedure – which she did not need. The fundamental problem was the lack of care coordination. One would like to believe that had her medical record been easily available digitally, the newly involved internist would have never even suggested the need for a cardiologist opinion and even if sent on, the cardiologist would have rapidly recognized the lack of need for the new device.
The lesson is one doctor needs to be the orchestrator of all of the patient’s care. A good PCP, like this one, coordinates the care of his or her patients with chronic illnesses and in so doing avoids excess referrals, tests, procedures and hospitalizations along with unneeded drugs or devices – all the elements that drive up the total cost of care – and in the process assures quality care, safer care and a close doctor-patient relationship. But sometimes a patient is elsewhere, sees a new physician and the medical history is not readily available. All too often as in this case, the patient ends up getting tests, images or procedures that he or she just does not need.
One of the most effective ways to reduce medical care costs is with good coordination of the care of individuals with chronic illnesses. As the story of Ellen above and of Henry from the earlier post exemplify, there is a strong tendency today for patients with chronic illnesses to either be referred to various specialists or else to go on their own. When this occurs without coordination, the visits add up, the number of tests and images ordered go up, the number of drugs prescribed rises rapidly and the number of procedures and even hospitalizations climb. Unfortunately, many of these are simply not needed – excessive and wasteful, not the best quality and obviously very costly. The value of a good digital medical record in both of these patients is obvious because communication among providers is critical to optimal care.

The primary care physician is in the best position to coordinate care. He or she knows the patient, the patient’s family and socio-economic situation and of course the patient’s various illnesses. Ellen did not need to see a second cardiologist and did not need the dual lead pacemaker. The PCP knew that “tired” was just her normal statement at every visit; not a reason to do more tests, add a drug or do a new procedure. It was unfortunate, indefensible but not at all uncommon that the new cardiologist did not make the effort to call the long time PCP. It would have been quickly determined that Ellen did not need a very expensive new pacemaker.

Henry suffered because he did not have a PCP. Instead he had four doctors, each one dealing with all of his problems and none communicating with the others. Once he had a single PCP, his prescriptions plummeted from 23 to seven, he felt better, had fewer drug-induced side effects and both he and his insurers were saving a lot of money.

Care coordination is critical; it improves the quality of care; it reduces risk; it reduces the costs of care; and it ultimately improves patient satisfaction. A good PCP (or occasionally a specialist) is needed to the orchestrator of that coordination. The electronic medical record has an integral part to play in robust care coordination.
Why, with all of these attendant advantages, do not all PCPs engage in excellent care coordination? I believe it is twofold – dollars and lack of training.

My new book, “The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You,” from which this post is adapted, will be published in February, 2012 by Potomac Books

1 comment:

Stephen Meyers, MD said...

In my view as a practicing family physician, time constraints may be the most significant obstacle in care coordination. There is often inadequate time to thoroughly attend to all immediate concerns, much more rarely extra time to call other care providers or wait for records to arrive.

Additionaly problematic is the "out of sight, out of mind" issue. It is simply not possible for a physician to oversee what is happening to each of his or her thousands of patients when they seek care elsewhere. Although inconvenient, and sometimes unrealistic, the burden largely rests on the patient's shoulders to make an additional visit to discuss with one's primary care physician any major decisions to be made.

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