Sunday, February 17, 2008

Robbing Peter to Pay Paul-The Fall of Primary Care and the Rise of Technology Medicine

If Peter is the primary care physician then Paul is the obsession we in American medicine have with technology and procedures, which frequently are of no benefit to patients. Technology used wisely can be wonderful, but when used inappropriately is potentially harmful to the patient and wasteful of resources. Perhaps the most painful example of this obsession is in end-of-life care, typified by the recent publication of articles extolling the virtues of end-of-life care administered in the intensive care unit (ICU).(1)

Some of the many reasons why the concept of knowingly providing end-of-life care in the ICU is inappropriate are:

1) Once it has become obvious to the ICU team that an end-of-life situation is at hand, the patient needs symptom control and along with the family, spiritual support. However, ICU care is technology intensive, with an inherent inability to eschew that technology regardless of its appropriateness. This was admitted by the authors of the above quoted article in their response to my letter. (2)

2) Certainly there are much better venues able to provide spiritual support than an intensive care unit with its hustle-bustle and crisis like atmosphere.

3) Energies expended by the medical care team on end-of-life patients in the ICU are not spent on other patients who have the capacity to improve and for which ICUs were developed.

4) The difference in cost between end-of-life care in a regular hospital bed and the ICU is staggering. (3) Some ICU doctors argue that fixed costs (nursing and equipment) in the ICU are such that decreasing the number of patients would not result in savings. (4) However, fixed costs would be decreased if patients who should be in hospice were not admitted to the ICU. Unfortunately hospitals have become mesmerized and addicted to this additional income!

But where is the primary care doctor in this situation, the physician the patient and family has learned to trust over the years and should guide patients during tough times? There is no mention of her/him in the ICU literature and from a national perspective because of severe financial constraints, primary care is in crisis. (5) This ICU scenario is a microcosm of our medical system. Technology is frequently used inappropriately, patients do not receive the care they need, patients who would benefit from more attention do not receive it because of diverted efforts, and the medical system pays exorbitantly for services that cannot accomplish a worthwhile goal. Because of the huge amount of funds going for nonsensical technology and procedures, primary care, the cornerstone of any nation’s health system, withers on the vine. This is a national disaster that must be addressed before our health care system can deliver adequate care to all our population. In future articles, I will discuss a physician based appropriate care committee review system with financial authority on the local, state and national level, to address patients on an individual basis. This would go a long way to solve this problem.
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1. Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. New England Journal of Medicine, 2007;356:469-78. (PMID 17267907)
2. Fisher KA. Communication about dying in the ICU. Letter to the editor. New England Journal of Medicine, 2007;356:2004 (PMID 17506162)
3. Angus DC, Barnato AE, Linde-Zwirbl WT, et al. Use of intensive care at the end-of-life in the United States: an epidemiologic study. Critical Care Medicine, 2004;32:638-43. (PMID 15090940)
4. Luce JM, Rubenfeld GD. Can health care costs be reduced by limiting intensive care at the end-of-life? American Journal of Respiratory Critical Care Medicine, 2002;165:750-4. (PMID 11897638)
5. Public Policy Committee of The American College of Physicians. Achieving a high performance health care system with universal access: what the United States can learn from other countries. Annals of Internal Medicine, 2008;148:55-75 (PMID 18056654)

Thursday, February 7, 2008

Universal Health Care: What’s Wrong with This Picture?

Survey results in a recent article in the New England Journal of Medicine(1) show Democrats and Republican have very different views about our health care system. Democrats are not happy with the system and want universal coverage, even if it means more government involvement and higher spending. Republicans, on the other hand, are more satisfied with our present system and are more concerned with controlling costs. They favor private insurance solutions and tax breaks to decrease the number of uninsured people.

Both sides miss the point. The question is not how to finance our health care system. The question is why do we spend more money per person than other developed country, but still have more than 47 million people uninsured and lower life expectancies? Current health care costs are running around $2 trillion a year – about $7 thousand for every man, woman and child.

The reasons for this are not difficult to understand. Some of our excess costs are attributable to higher prices for medical goods and services and considerably higher administrative costs. But the big problem is our technological and procedural style of medicine, fostered by the reimbursement system of Medicare and other insurers. We pay for procedures and not for clear thinking. There are several reasons for this, and I’ll examine each of them in detail in future posts.

1. Primary care (family doctor, general internist and pediatrician) has been under funded for decades, resulting in an acute shortage of primary care physicians. The old-fashioned doctor/patient relationship that provided critical insights into individual patient care is virtually non-existent.

2. There is no system of physician oversight in either hospitals or nursing homes to make sure that patients are receiving only beneficial care and not care that means a bigger tab to bill the insurance companies or Medicare/Medicaid, without any real advantage for the patient.

3. There are no controls on drug and medical device manufacturers in terms of research validity and funding, lobbying Congress to approve their products for Medicare/Medicaid coverage, or advertising their wares to the public.

4. End-of-life care in large teaching hospitals is more costly, yet the death rates are higher. There is more emphasis on expensive high-tech procedures, whether the patient will benefit or not.

Approximately 17% of gross domestic product now goes to health care. That’s a significant drag on our economy, especially when compared to other countries. There is no question we need universal coverage, but to get it without bringing our economy to its knees we must change the way we practice medicine.
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(1)Blendon RJ, Altman DE, Deane C, Benson JM, Brodie M, Buhr T. Health Care in the 2008 Presidential Primaries. New England Journal of Medicine, 2008;358:414-422 (PMID 18216365)