elephany

Am I the only one seeing the obvious?

There has been lots of talk about reforming healthcare in a way that is budget-neutral.  The president has touted the use of EMR and of preventive medicine to save money.  Many have rightly pointed out that both of these are unlikely to save money.  EMR will only really save money when it is inter-connected, allowing healthcare workers to have accurate data to make decisions.  Preventive care will actually probably result in more utilization in the short run, not less.  Ordering more mammograms, for example, will incur a cost by itself, but even more significant will be the number of ultrasounds and biopsies in response to abnormal tests.  The savings will hopefully come down the line when less women have advanced disease requiring hospitalization and chemotherapy.  Both of these suggestions have merit, but only over the long-term.

So then the question comes up: how do we save money in the short run?  Answer: primary care medicine.

Wait...didn't I just say that prevention would only save money down the road?  Yes, I did.  But primary care medicine is not all about prevention; most of my day is spent either treating acute illnesses or managing chronic problems.  In both of these instances (despite the surprisingly naive things reported elsewhere), I can save the system money quickly.  Here's how:

1.  Diseases do better when treated.

Treated diabetics do better than those who are not treated.  It's better to have a blood pressure of 110/70 than 190/100.  It's best to get to the doctor early if you have pneumonia.  All of these things are basic; they are medicine 101.  If we argue these things, we argue the whole basis of what doctors do.  We intervene to lengthen life and to maximize the quality of life.

This is not insignificant.  One hospitalization for uncontrolled diabetes, stroke, or heart attack will more than make up for any costs I incur as a PCP.  It doesn't take much good medicine to decrease cost to the system.

2.  Our goal is to keep people away from specialists and hospitals.

Specialists are essential for care - we need people who can treat cancer, deal with heart attacks, and do surgery.  Hospitals are great things too (stating the obvious).  But don't you want your doctor to make it so you don't need either of these?  I really hope I never need an oncologist or a cardiologist.  I really hope I never spend time in the ICU.  Working with someone to reduce this risk is absolutely desirable.

The problem is that the more work we give specialists, the more cost goes out of control.  Not only are the specialists themselves and the procedures they do expensive, they utilize hospitals much more.  That's not wrong; it's just not a good way to cut cost.  Staying healthy is a good way to keep from seeing doctors and using hospitals (again stating the obvious).

Primary care is the one field whose success would mean lower cost.  If I do my job really well, I see my patients infrequently (because they are healthy) and they don't need other care elsewhere.  That is, of course, unrealistic to expect for all of my patients, but it surely should be my aim with each of my patients.  I don't want them to be sick.

3.  Relationships mean better healthcare

When I am unfamiliar with a patient, I have to do much more to figure out what is going on.  I spend a lot of time asking questions about a person's past and trying to figure out their personality.  Docs are pretty good at this, but there is no question that I get to answers much quicker with someone who I have seen for many years.  Studies have borne this out: the better the relationship between doctor and patient, the better the quality of care.

The patient's comfort with the doctor may be even a bigger factor.  When a patient knows and trusts their doctor, they are much more likely to listen to what their doctor has to say.  If they know that I am not an over-prescriber of drugs or a high-utilizer of tests, they will trust me more when I do recommend them than they would a physician they had never met.

Again, better quality care is better than poorer quality care (see point 1) and will save money.  Would anyone question the idea that having a physician who knows you well, oversees all of your care, and helps you coordinate it is going to save money and prevent illness?

4.  PCP's (should) order less tests than specialists

I put the parenthetical "should" in the sentence because I do know PCP's who don't practice good medicine.  Either they own lab or x-ray equipment that they want to use, or they are stuck with the idea of being a "gatekeeper" - acting more as an envoy to specialists than as a clinician and diagnostician.  There are bad doctors in all areas (bad teachers, lawyers, and zoo keepers as well).  But good primary care will act differently than good specialty medicine when confronted with a problem.

For example: when a person presents to me with chest pain, I do an EKG less than 50% of the time (probably less than 20%).  Why?  People with asthma, bronchitis, chest wall pain, and anxiety can have chest pain as a symptom.  I am used to seeing the general public, which is a population with a minority of people having significant heart conditions.  A cardiologist, on the other hand, is used to seeing high-risk people.  To them an EKG is a routine test, as the overwhelming majority of their patients do have heart problems (duh).

The same holds true for neurosurgeons and MRI scans, neurologists and headaches, and pulmonologists and cough.  They are all used to seeing a sicker population and so will tend to look at the patient through that filter.

My job is to sift through the chest pain and send those patients with real heart problems to the cardiologist - keeping the rest for myself.  They don't want to see every chest pain I see.  So again, me doing my job well saves money quickly.

------

The idea of prevention is often thought of in terms of screening tests (mammograms, colonoscopy, cholesterol testing).  This is a minor part of prevention in my life.  The most important prevention I do is to keep diseases quiet and keep illnesses from getting bad.  I do this 10 times more than I do classic "preventive medicine."  And the turn-around on this with respect to cost is very fast.

Kevin Pho has done much to champion primary care, as have many others.  The discussion, however, sometimes misses its real benefit.  If we can somehow give PCP's motivation to use hospitals and specialists less (by doing good medicine), we will hit the mother-load of savings.  PCP's are in the unique position of being paid to keep people well.  We don't want disease.  We are happy when our patients don't need us.

That's our job.  And if somehow primary care would be really rewarded, the system would see a huge drop in cost.

17 Comments