Friday, April 4, 2008

The Health Care Mess - Medical Society Responsibility

The American College of Physicians (ACP) recently presented an elegant model of primary care in the Annals of Internal Medicine. (1) They also made other suggestions that would greatly improve health care in The United States. What they failed to do, however, is discuss why primary care is in such a shambles and what their role should be as a professional organization. Primary care is the backbone of any successful health care program. Patients and their primary care physician – what we used to call the family doctor – can build relationships that bring much better care in the long run. Why? Because the primary care physician knows the patient as a “person” not just a jumble of symptoms and diseases. That’s of the utmost importance when it comes time to make decisions about care, and for a physician to use judgment about what’s appropriate for a particular patient.

Approximately one-third of care is inappropriate to the tune of $600 billion dollars a year. (2) That’s a lot of money that could be directed to primary care, provide universal access and make our health care system less of a burden on our economy. The ACP should take a leading role in addressing the excessive use of technology that frequently does not benefit the patient, particularly patients at the end of their lives. (3) If the primary care system was strong, there would be a vital link between the patient and the hospital that would facilitate much better decisions about what would be in the patient’s best interest.

The plain fact is that hospitals and physicians make more money with expensive procedures whether they help the patient or not. A classic example is using coronary artery stents in patients in whom medications alone are equally efficacious. (5) The growth of specialty hospitals and procedurists is a result – not more physicians practicing primary care. At this time there’s just not enough prestige and money in it.

Most of the overuse of technology and procedures occurs in large teaching hospitals. (4) What kind of message does this send to young physicians in training? Does it teach them to build relationships with their patients? To use their judgment to decide what would benefit a patient the most? Or does it teach them to throw every procedure they can into the mix and bill handsomely for it?

Medicare has attempted to adequately fund primary care. However, because of the excessive funding for specialists and procedures, their efforts have failed. (6) If the American College of Physicians is serious about its goal of excellent primary care for all, then it must take an active role in promoting the appropriate use of our medical resources. Only with a return to a strong primary care system will we see good preventative care and the delivery of appropriate treatment for everyone.
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1. Public Policy Committee of the American College of Physicians, Ginsburg JA, Doherty RB, Ralston JF Jr. et al. 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)
2. Garson A Jr., Engelhard CL. Health Care Half Truths; Too Many Myths, Not Enough Reality. New York: Rowan and Littlefield; 2007, Page 17
3. Barnato AE, McClellen ME, Kagay CR, Garber AM. Trends in inpatient treatment intensity among Medicare beneficiaries at the end-of-life. Health Serv Res 2004;39:363-375 (PMID15032959)
4. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucus FL, Pinder EL. The implications of regional variations in Medicare spending, Parts I&II. Annals Intern Med 2003;138:273-298 (PMID 12585825 & 12585826)
5. Mitka M. Cardiologists get wake-up call stents. JAMA 2007;297:1967-1968 (PMID 17488954)
6. Ginsburg PB, Berenson RA. Revising Medicare’s physician fee schedule – much activity, little change. N Engl J Med 2007;356:1201-1203 (PMID 17377156)

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