A Crisis in Primary Care

We are entering if not already in a crisis of primary care. Each of us needs a competent, caring and available primary care physician but that is less and less possible. Many can’t find one; others cannot afford one; and others have one but cannot get adequate time and attention from him or her. PCPs will tell you that they do not have enough time with each patient; are overwhelmed with paperwork and mandates; and are earning less and less per year. There are about 1000 graduating physicians entering primary care per year in the USA but about 3-4000 retiring. Average income after about ten years in practice of $150,000 has been stable or decreasing for some years while the costs of practice including staff wages, rent and utilities, malpractice insurance and supplies has been rising. Most medical school graduates have about $155,000 in debt to pay off. To make ends meet and retain the same income, PCPs are seeing more patients with longer days and shorter visits. This is not good for them and it definitely is not good for you. Basically they have a non-sustainable business model today as a result of the reimbursement system through our commercial and governmental insurance system.
To counter the problem, more and more PCPs are taking steps to increase their income while decreasing the number of patients seen per day. Some approaches are frankly disappointing such as the doctor with a sign in the waiting room that you may “only raise one problem per visit.” A colleague told me last week that her internist is no longer taking Medicare. She will have to pay for each visit. Perhaps not a problem if you only go for an annual exam and then once or twice for minor problems. But if you develop a complex chronic illness that requires multiple visits it could add up quickly, especially for someone on a fixed income in retirement. Other PCPs are opting for “retainer-based” practices, sometimes called concierge or boutique practices. Here you pay $1500-2000 [or more] per year and in return your PCP reduces his or her practice from 1800 patients to 500 and guarantees that you can be seen the same or the next day, that he or she will be available by cell phone and email 24/7, will visit you at home, will meet you at the ER as needed, and will care for you in the hospital and the nursing home. And each visit will be as long as needed for you and your issues. This is the way it used to be and is the way it really should be now but is not. Another advantage of this type of system is that it becomes a true relationship again between the doctor and the patient with the patient contracting directly for services from the physician – not through a third party. The downside, of course, -- this is extra money out of your pocket since you will still need your insurance for specialists and hospitalization.
What is clear is that the current system does not work and either PCP reimbursements by insurers will go up or more and more PCPs will either retire early or switch to retainer-based practices.

Putting It Together To Bring Down Costs

President Obama is working hard to address the issues surrounding health care in the USA. Two days ago he hosted a group representing many of the major providers such as physicians, hospitals and pharmaceutical companies. They promised to work to reduce the rate of rise of costs of care over the coming ten years. No specifics were given out. Here is what I would suggest as the first steps.

If we take the comments from my last few blogs and put them together, we see that a few critical forces have come together to push up the costs of care. To be sure, there are other reasons for the rising cost of care and I will address them in later blogs. But these few are they key ones and are the ones to aggressively address now if we are ever to slow the rise of expenditures much less actually bring them down. Here they are:

Our population is aging – simply stated, “old parts wear out.” We have bad behaviors – poor nutrition, overweight, lack of exercise, stress and tobacco with many of these starting in childhood. Both age and behaviors are leading to the development of complex, chronic diseases [heart failure, diabetes with complications, cancer, etc]. This is much different that the acute illnesses that we generally think of such as appendicitis or pneumonia. In those cases a single physician can treat them and the result is a cure. But these chronic illnesses once developed persist for life and they require the expertise of many providers.

These chronic diseases are expensive to treat – today they consume about 70% of all US health care expenditures although this care is going to only about 10% of the population.
But our care system is poorly coordinated and this results in far too many doctor visits, procedures, test and even hospitalizations. That is the reason for the excess costs and these could be brought down with resulting improved quality of care, safer care and more satisfied patients.

What is needed, more than anything else, is a cadre of primary care physicians [or sometimes specialist a physician] to carefully coordinate the care of those with chronic illnesses. Without question, this approach will bring down costs.

Sounds simple and is in concept but the reality turns out to be not so easy

Personal Behaviors That Damage Our Health

A very important reason for medical care cost escalation has to do with our own personal behaviors. We are a country of people who are overweight --one-third are overweight and one-third or more are frankly obese --, under-exercised, poorly fed from a nutritional perspective and highly stressed. And it gets worse each year. Even children have progressively declining physical activity from about three hours per day at age nine to less than an hour by age fifteen. And this will correlate to obesity beginning in adolescence. Twenty per cent of us still smoke tobacco. These are some of the major reasons that medical costs will rise in the future. Diabetes will accelerate to epidemic proportions, heart disease will follow, arthritis will be exacerbated by obesity, life spans will be shortened and along the way there will be enormous medical bills to pay. We need a government that encourages good health, regardless of the economic interests that such a program will affect. It will mean less fatty food, less red meat, less whole milk and cheese on our pizza, less sodas [and everything else made with high fructose corn syrup], less prepared and take out meals and more home cooking, more whole grains (whole wheat, brown rice, oatmeal) and a real change in the cereals sold in supermarkets. We need to shop the periphery of the supermarket and leave the aisles with all the prepared foods alone. We still smoke in high numbers with all too many teenagers picking up the habit. They will incur the wrath of lung cancer, heart disease, chronic lung diseases and others in the years to come. And we must finally come to accept that weight gain is a function of the number of calories consumed minus the number expended by exercise. That’s so simple but apparently so difficult that we try all sorts of diets that ultimately don’t work but cost lots of money and frustration. Chronic stress is a cofactor in heart disease, back pain, gastrointestinal disorders and many others. Some alcohol may be good for our heart but it is never good to drink and drive yet all too many do so. At the same time many people do not wear their seatbelts. Add up all these adverse behaviors and they have a very marked effect on the diseases that occur – chronic, complex diseases that last a life time and which are very expensive to treat.

Lack of Care Coordination

The switch from acute to complex chronic diseases and the wide variation in care patterns are closely related. It is the complex chronic diseases that need the most attention and hence are most expensive to treat. But as a country we have long had the tradition of the independent, autonomous practioneer in the community taking care of us. This was fine for acute illnesses. The physician could either treat you him or herself or else would refer you to a particular specialist for needed care. Maybe to the surgeon to remove your appendix or gallbladder. Once the surgery was done, the problem was “cured.” Not so with chronic illnesses. Often the patients need multiple physicians, each with different skills and expertise such as the cancer patient would need a surgeon, a radiation oncologist and medical oncologist. But these three and the primary care physician are not likely to be well coordinated. They may have offices in different parts of town and possibly use different hospitals for some of their work. Communication is weak and the PCP often does not feel able to serve as the coordinator or quarterback. And, since these chronic illnesses often occur in older individuals, there is a good likelihood that other illnesses will develop concurrently. Maybe high blood pressure, heart failure or diabetes with complications. And so off to more specialists who do not communicate well and who do not understand the implications of the other illnesses, the other medications, etc. the result is often extra doctor visits, extra procedures, tests and X-rays and even extra hospitalizations than would have been necessary with well coordinated care. Unfortunately, this is the way medicine is practiced today and it is a real problem. It means that care is not as good as it should be or could be, not as safe as it should or could be, not as customer [patient] friendly as it should be or could be, and it means that it costs far too much.

Care Costs Vary By Geographic Region

When thinking about health care reform it is important to realize that there are wide variations in care expenditures from geographic region to region. One might assume that those regions with higher expenditures reap better health but that is simply not the case. Unfortunately, much of medical care is not delivered based on evidence of efficacy but rather on long standing practice, tradition or training many years before. Indeed there is some pretty firm data that suggests that where there are more specialists, and where there is “more capacity” that it will get used more and drive up the total cost of care. Some very interesting studies coming from Dartmouth Medical Center have tracked this over the years. In a recent analysis of Medicare data from 2001-2005, the Dartmouth investigators looked at the last two years of life for Medicare recipients with complex chronic diseases such as heart failure, kidney failure and dementia. They picked those two years of life because they account for about one-third of all Medicare expenditures. What they found was a wide variation in costs or expenditures due to a wide variation in the use of services such as specialists, intensive care unit days, hospital days and so on. And this related directly to local medical care capacity. Where there was more capacity, there was more use and therefore higher expenditures. On average these Medicare patients each accounted for about $46,000 of expenditures by Medicare during those last two years of life. But in states with high capacity like New Jersey the average expenditures per patient were $59,000 and in an area like North Dakota where capacity is relatively low the average expenditure was $33,000. Certainly a wide difference and yet they could find no significant difference in the quality of care or patient outcomes. So they made a suggestion. If the use rate across the country was equivalent to the use rate in Minnesota, which is also where the Mayo Clinic is located, Medicare would have saved $18 billion per year for each of the years 2001-2005. They were not suggesting trying to bring it down to the North Dakota expenditure rate but they were suggesting that there was no reason why it could not be brought down towards the national average, an average which just about everyone would agree can produce a very effective medical result. The Dartmouth investigators pointed out that the “variations allow us to rule out two overly simplistic explanations for spending growth. First ‘technology’ is clearly an insufficient explanation: residents of all US regions have access to the same technology.” Second, these regional differences cannot be caused by “differences in the current payment system” since they all were on fee for service Medicare plans. “The causes must therefore lie in how physicians and other respond to the availability of technology in the context of the fee-for-service payment system.” They studied physicians in various regions and were able to show that physicians in all regions recommended specific evidence-based interventions for similar problems. But those in high consumption of resources areas were much more likely to recommended discretionary services, such as referral to a subspecialist for typical esophageal reflux. It was this use of discretionary services that resulted in the wide variation in per capita spending.

Complex, Chronic Illnesses That Last A Lifetime

Our medical care system has developed around diagnosing and treating acute illnesses such as pneumonia, a gall bladder attack or appendicitis. The internist gave an antibiotic for the pneumonia and the patient got better. The surgeon cut out the gall bladder or the appendix and the patient was cured. But as the population ages, more and more individuals are developing what I will call complex, chronic diseases like heart failure, diabetes, chronic lung disease or cancer. These are diseases that remain with the individual for life and these diseases and patients need a different approach to care. These patients need long term care, not episodic care; they need a team-based approach where one physician serves as the orchestrater or quarterback and manages the myriad physician specialists and the other caregivers to allow for a unified, coordinated care management approach. And these diseases are very expensive to treat today; 70% of our medical care expenditures go to treat 10% of us, those with these chronic illnesses of health care costs in America. As I will describe in detail later, it will take a new approach to organizing the care of these patients to both improve care and reduce the costs. But the new approach actually exists in some locations – the need is to understand what works and then replicate it nationally.

America Has a Sick Care Not a Health Care System

We Americans like to pride ourselves as having the best healthcare system the world but unfortunately that is not the case. We have a medical care system, not a healthcare system. We give lip service to prevention and spend only about 3% of our $2 trillion in medical expenditures on public health. By many measures we do not rate favorably compared to many of the other industrialized societies. As citizens we have behaviors that are driving more and more illness, illnesses that at chronic, complex, lifelong and life shortening. That $2 trillion is by far more than other nations spend per capita and it is seriously and adversely affecting businesses, government and each of us. Meanwhile, we may be pleased with our doctor but not the delivery system as a whole. Quality is subpar, preventable errors are rampant and some 47 million of us are without insurance access to medical care – the only such industrialized country. Health care reform is now a topic of great interest but politicians and media focus on the access issues predominantly, cost issues somewhat and the quality, safety and prevention/ public health needs only rarely.
Let’s take a closer look at what we have today. The current system of care focuses on “disease and pestilence.” It is a disease oriented system and certainly not a health management system nor a patient-oriented system. Mostly, this is due to a reimbursement methodology that under-rates the generalists and tilts toward those that do procedures. That is not what we need; what we need is a payment system that rewards the generalist for working in rural or socio-economically deprived areas, for taking the time to listen to the patient, for being attuned to prevention and wellness management. Today, that is just not where we are in America. So we need a change to a system that is focused on disease prevention, health promotion and with ready access to primary care and providers. Then, when necessary, access to specialists, hospitals, rehabilitation and all of the other requirements for good medical care when disease or injury does occur.