Primary Care

I mentioned that I attended a conference a few weeks ago of the Institute for Healthcare Improvement, where doctors thought about how to reinvent their own clinical practices. The conference was not classic CME (continuing medical education) in the sense that they were not, for instance, learning that this drug was better than that drug for diabetes, or that this device was better than that one for a failing heart. They were addressing how they organize their practices and deliver the care to make it both more efficient and higher quality. And they were encouraged to think about being a doctor—or a patient—in a way they had perhaps not thought about it for some time.

In the big hallway in the convention center (this was Texas, so the hallway was indeed big), conference organizers put up lip charts and invited docs to scrawl their responses to three key questions. People in politics and policy circles are so busy drawing up models and plans and simulations for health care reform, they sometimes forget what the docs may have to contribute. So here are some of their answers from those flip charts, a peek into the minds of caregivers who care.

What if we told you a program in North Carolina reduced Medicaid spending in one year by close to $244 million while improving care? The N.C. program offered primary care doctors a $3 per-patient, per-month payment to manage the patients on top of the usual fees for clinic visits. It also organized a multi-disciplinary team of medical personnel to assist the patients. The result: doctors spent more time with patients, coordinating treatment for chronic conditions and reducing hospitalizations. The overall quality of care improved.

The Patient-Centered Primary Care Collaborative (PCPCC)-a broad coalition of business leaders, policymakers, primary care physicians, and other stakeholders is looking carefully at success stories like North Carolina's to see how our whole health care system can redevelop our primary care infrastructure to control costs and improve quality in our country. After all, there's a reason it's called primary care.

More bad news for those of us who plan on getting old some day. The Institute of Medicine just released Retooling for an Aging America: Building the Health Care Workforce which reminds us there are not going to be enough doctors and nurses to deal with the geriatric needs of the 78 million baby boomers who start reaching age 65 in 2011. The authors said Medicare, Medicaid, and other health plans should pay higher rates to encourage more docs to learn about geriatrics. It also recommended training for family members and other aides who do a lot of the heavy lifting (literally and metaphorically) for the elderly. In many parts of the country, it noted, dog groomers and manicurists are required to get more training than the people who take care of our seniors.

"We face an impending crisis as the growing number of older patients, who are living longer with more complex health needs, increasingly outpaces the number of health care providers with the knowledge and skills to care for them capably," said committee chair John Rowe, professor of health policy and management, Mailman School of Public Health, Columbia University, New York City.

Tired of waiting for Washington to fix health care, doctors across America are doing it themselves. I just attended a conference in Dallas where hundreds of physicians exchanged ideas on how to improve the quality of care they deliver, make their clinics more efficient—and rediscover the joy of practicing medicine. In future posts, we'll touch base with some really smart and dedicated people we met there and highlight specific innovations that got our attention—new ways of reaching hard-to-serve populations, managing chronic diseases like diabetes, involving patients in their own care, new twists on "shared visits."

We may not be able to tamp down diabetes in America but at least our skin will be flawless.

For a variety of reasons —including money —lots of young doctors choose fields like dermatology and plastic surgery instead of internal medicine, geriatrics and pediatrics. As we tackle national health reform, we need to make sure we put primary care back on center stage.

Two influential physicians, Joel S. Levine, chairman of the Board of Regents, American College of Physicians and Christine K. Cassel, president and CEO, American Board of Internal Medicine, chimed in about the "upside down" health care system and distorted incentives in a letter to the editor of the New York Times today. They were responding to the recent story, "For Top Medical Students, Appearance Offers an Attractive Field."

"The fact that so many medical students are choosing lucrative specialties like dermatology over internal medicine should be a clarion call that our health care system needs an overhaul," they wrote, noting that primary care docs can't hope for the $2,000-an-hour fees that a physician can reap on a cosmetic procedure.

Dr. Benjamin Brewer, in his Wall Street Journal column (subscription, or read a summary in the Wall Street Journal health blog) wonders: who will take care of the 47 million uninsured in a system that already undervalues family medicine and primary care?

We would suggest that the uninsured are getting care – not enough care, too- late care, expensive emergency room care instead of more appropriate and cost-effective primary care. But Dr. Brewer’s central point is correct. Our system gives short shrift to primary care and is chockfull of incentives for fragmented specialization. In the health care system we envision for the future, primary care doctors (internists, family doctors, pediatricians, geriatricians, perhaps for some women OB/GYNs) would play an elevated role in coordinating patient care. And they would be paid for doing it well.

Apologies for the irony of blogging about a two-year old journal article titled "MIssed and Delayed Diagnoses" but Paul Levy on his "Running a Hospital" blog recently brought it to our attention. The study adds to the mounting evidence that the way our $2 trillion system tilts toward highly paid specialists versus primary care doctors may be hazardous to our health.

Levy points out the 2006 Annals of Internal Medicine study ("Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims" by Dr. Tejal K. Gandhi, et al.) about diagnostic errors that harmed patients—or contributed to their deaths. Common errors included not ordering the right tests or not interpreting tests correctly, not providing follow-up, or not doing a thorough enough physical exam. Sounds shocking until you remember that primary care physicians have 20 minutes or so with a patient.