Primary Care

Sitting in traffic Sunday with the rest of those migrating Turkey Day pilgrims, we caught a story by Karen Brown on NPR's All Things Considered. It seems long lines aren’t limited to the highways of Pennsylvania, and that many of those 440,000 newly—covered by health insurance in Massachusetts are having trouble getting access to a primary care doctor.

The story should be familiar to those who have followed closely the developments of Massachusetts. We've written in the past about some of the challenges facing the state's reform efforts.Physician shortages are certainly high on the list.

Stop the world. Primary care doctors want to get off.

A survey by the Physicians' Foundation, which promotes better doctor-patient relationships, found that nearly half the primary care physicians would do something else if they could. Patients aren't the headaches, as much as red tape from both private insurers and government programs.

We already have a shortage of primary care doctors (family medicine, internal medicine, pediatrics, geriatrics etc). A CNN report on the survey noted that the AMA recently predicted the shortfall would grow to around 40,000 by 2025. For reasons of prestige, money and lifestyle—some of which is built into a medical payment system that favors specialty medicine over primary care—med students are opting for specialties like orthopedics and dermatology over primary medicine. (The New England Journal of Medicine recently published a series of Perspectives on Primary Care, and the full texts are available free here)

More evidence that it's not just the uninsured clogging up our ERs. It's the whole flawed health care system clogging up the ERs.

A study in the Journal of the American Medical Association, described in USA Today, shows that emergency room crowding has multiple causes. Yes the uninsured are part of the problem, and in some cities they are a big part of the problem, but typically the uninsured try to avoid ERs because they are so expensive.

Even author-recluse Don DeLillo knows the value of a good internist. In White Noise, he observed that:

In New York ... people ask if you have a good internist. ... "Who's your internist?" someone will say in a challenging tone. The question implies that if your internist's name is unfamiliar, you are certain to die of a mushroom-shaped tumor on your pancreas. You are meant to feel inferior and doomed not just because your inner organs may be trickling blood but because you don’t know who to see about it, how to make contacts, how to make your way in the world.

Post-modern angst aside, we'd have to agree with DeLillo about the value of a good internist. Primary care is the foundation of our health care system, and strengthening that foundation can lead to better outcomes at lower costs.

But what exactly does an internist or primary care physician do that makes them so important? The Happy Hospitalists has a good explanation today about of what it takes to be a "doctor's doctor." He writes:

An article by Brian Rank, M.D., in the New England Journal of Medicine on executive physicals-the Bentley of Cadillac care-is generating a lot of buzz in the blogs (here, here, here). The main message: more care is costlier care, but it's not necessarily better care. Rank writes:

Executive physicals also reinforce a related misperception - that costlier is better, that a $3,000 examination must be worth more than one that costs 1/10 of that amount. This is an indefensible idea that should not be promoted by the health care industry. Even as individual hospitals sell these services for exorbitant fees, gratuitously overusing our health care resources, our system as a whole is appropriately straining in precisely the opposite direction, toward cost-effectiveness, transparency, competition, and accountability. With its outrageous cost and unproven efficacy, the executive physical is almost a parody of the high-cost, low-return procedures that prudent companies rightly want clinicians to eliminate for other employees. [...]

This year's MacArthur "genius" grants included three extraordinary physician-innovators. All three are practicing physicians, taking care of patients. All three are also showing us how we can improve the whole system, not just for a handful of patients lucky enough to have exceptional doctors. Diane Meier is a pioneer in palliative care, illustrating how we can dramatically improve care for the seriously or terminally ill—and save money while we're at it. Regina Benjamin provides primary care to the poor in unbelievably difficult conditions in rural Alabama. Peter Pronovost is a critical care physician who has shown hospitals simple, inexpensive ways to prevent lethal infections. What's really phenomenal—and different—is that if you try to talk about some of these concepts to policymakers in Washington, at least some of them will know what you are talking about. That wasn't as true just two or three years ago, and I think it shows a growing awareness that health reform has to do more than cover people. It has to cover people in a health care system that is both more efficient and more compassionate.

While our colleague Paul Testa was going through the latest numbers on the incredibly shrinking primary care work force, we were over at the Health Affairs session listening to Robert Berenson of the Urban Institute talk about how to build the Medical Home, which is in some ways a souped up 21st century version of primary care.

Bob (who has guest blogged for us in the past) said a lot of docs don't like primary care in our current world because of what he called the hamster syndrome. They feel like they are hamsters spinning on wheels in a cage, unable to keep up, unable to move ahead. The medical home is supposed to restore primary care's rightful place in the healthcare universe, while as Berenson wrote in the current issue of Health Affairs, "providing a source of confidence, advocacy, and coordination for patients as they encounter the disconnected parts and often daunting complexity of the health care system." Advocates of medical homes stress their importance in managing chronic diseases. Naturally, to make them work, we're going to have to pay primary care providers better and differently if we want care coordination and oversight to replace piecemeal, pay-for-procedure medicine.

Crime doesn’t pay. Unfortunately, neither does primary care—or at least not enough, especially when you’re carrying an average of $139,000 in debt into your residency.

Two new studies published today in JAMA continue to sound the alarm bell about the future of our physician workforce. One, a survey of nearly 1,200 fourth year medical students, found that only 2 percent planned to go into general internal medicine. More than 23 percent planned a career in internal medicine—a field generally associated with primary care but which also contains more lucrative subspecialties.

The primary reasons pushing these doctors away from primary care: income and lifestyle. Close to 65 percent believed they would earn less income going into internal medicine, 68 percent believed they would have to deal with more paperwork and 42 percent were turned off by the need to bring work home with them as an internist. (See our colleague Joanne Kenen's post today about medical homes, primary care and the hamster wheel.)

You've heard of a medical home? What about a medical home-away- from-home, or more specifically a medical-home-at-the-office?

Stacey Burling at the Philadelphia Inquirer writes about the national trend of having company doctors or company clinics to provide primary care, wellness, screening and related services at the workplace. The idea is to keep workers healthy—and keep them out of the emergency room when they are sick. And, they hope, put a dent in rising health care costs. Bunting writes of Cardone Industries, which remakes auto parts:

Too many of its 4,000 employees, a melting pot of immigrants from dozens of countries, lacked primary-care doctors. Rather than deal with problems early, they'd wait until they were really sick, then head for emergency rooms, the priciest place to get health care. On top of that, a small but growing number of workers was turning down the company's health insurance plan because it was too expensive.

Lucy van Pelt used to charge five cents for advice. That's peanuts compared to what some patients will pay today for the services of "health care advocates," according to the Boston Globe. And although the intent is to help people navigate the system, their very existence illustates some of that system's biggest problems.

These firms specialize in coordinating a patient's care and helping them navigate our complex and often overwhelming health care system. What doctors to see, what treatments to seek, where to go with an emergency at 3:00 a.m.—they'll answer all your questions—for a price that can range from $150 an hour to $100,000 a year.