Thursday, May 14, 2009

Primary shortages?

This is an off the cuff, outside the box ramble.

I was talking to a buddy of mine in the OR locker room the other day about how it seems the body starts to break down once you hit that 35th birthday. (Except mine of course. I'm a machine who will never get sick.) He mentioned that he was diagnosed with Essential Hypertension about a year ago. A routine yearly physical exam noted a diastolic BP of over 100. His primary care doc put him on an ACE inhibitor and, with time, his pressures have drifted back to within normal limits. Since his diagnosis, he has been seeing his doc every three months for "check-ups". I thought that seemed rather intense. He agreed. He waits in the office for 45 minutes, gets his pressure taken by a nurse, the doctor comes in, listens to his heart, tells him everything is fine, see you in three months. He's paying over a hundred bucks a month for the anti-hypertensive. And then there's the fifteen dollar co-pay for every visit.

I understand that primary care physicians cannot afford to have too many empty office hours. Staying booked three months in advance is not only stress reducing, but it's unavoidable if one wants to remain a financially viable entity. But we're talking about a 36 year old male with controlled hypertension. Does he really need to be seen four times a year? And does he need to be on an expensive ACE inhibitor?

It's dogma that primary care physicians are both underpaid and overworked. This is pretty much undeniable. Advocates also aver that any universal health care reform is going to require more primary care docs, because they're already maxed out in terms of availability.

I ask: Is this part entirely true? Is there any evidence to suggest that a 36 year old male needs to see his PCP four times a year? Or that the 50 year old obese female with hyperlipidemia on Lipitor needs follow up appointments every two to three months? Or the 60 year old diabetic who also sees an endocrinologist for blood sugar management?

What I'm getting at is this: Is the jam-pack scheduling driven by medical need or is it more a financial necessity? Will primary care scheduling patterns change once reimbursement is increased? Let's say you get paid the same no matter if you see 30 low maintenance, known patients versus 10 complicated or new patients. Which is more preferable? I'm not certain everyone would choose the latter. Sometimes it's nice to cruise quickly through a day without expending a lot of mental anguish. As a general surgeon, my schedule is very flexible, even unpredictable at times; I have no idea what I'll be doing or who I'll be seeing three weeks from now. I'd be curious to hear from primary care docs in the trenches....


HMS said...

It is extremely difficult for a PCP to stand alone in private practice. The burnout and noncompetitive financial return are among the reasons why some leave the field. Meanwhile, it’s growing popular (in Pacific NW at least) for PCP to practice in polyclinics for mutual coverage; it helps ease-off the workload.

Would PCP drop patients if financial return increased? I suppose it depends largely on how much he/she likes what he/she does.

HudsonMD said...

I have no defense for the PCP in question. That type of patient once the BP is controlled is seen by me at most twice a year (one of those being a CPE). I have alot of diabetics that are seen every four months and alot of CHF patients that i may see every month or two (mostly done to keep them compensated and out of the hospital). This patient you mentioned is on an ACE (and i am not sure which one that costs $120 a month!) I can treat a patient with two drug htn, high chol and two drug DM for $20 per month cash paying! This is a significant problem with our Health Care System and our Health Care Dollars. The office visits are small-time. It is the expensive drugs and treatments (used when cheaper alternatives are of equal efficacy) that are a major problem. I do not force patients to see me anymore than I feel I need to keep them healthy and safe on the drugs they take (monitoring liver tests, kidney function etc). We talk about preventative medicine to keep people healthy, but my Preventative Care Codes are some of the lowest reimbursed. A Level 5 Follow-up appointment pays better then any Preventative Care Code. I do not have all the answers, and I do my fair share I am sure to make it less efficient. But we all need to help cut costs. Best case scenerio some of those cost savings may eventually end-up in my pocket.

HudsonMD said...

Also I will not take part in a Capitative System. This breeds laziness and motive NOT to see patients.

Any comment Buckeye on Nancy Pelosi??????

Anonymous said...

Expensive Ace Inhibitors??? Is this 1989??? I like Lisinopril myself, $10 for a 3 month supply and thats probably high...If they get the Cough, switch em to somethin else on the list...
Nancy Pelosi?? One more treatment and she'll turn into a giant Clostridium Botulinum...Allthough I bet she was pretty hot back before Penicillin...


Joseph Sucher, MD FACS said...

Reimbursement, education, volume, expectations and resource allocation all need to change. That's the problem. The system is so incredibly broken that it looks to be impossible to fix, and to fix it requires attacking all the interlocking pieces.

To simply reimburse higher won't do it, as then only one of two things can happen. The PCP will make more and keep working as hard (still no improvement in system, just better paid PCP), or the PCP will lower their volume (now system is worse, as the patient ability to see PCP is worse).

I am very disappointed in the whole system because I don't see any serious effort to change it. They applaud a 2 million dollar over ten year reduction by payors... something that amounts to a rounding error for the future budget of health care. Its all a shell game of everyone looking out for their own turf. Worse.. they pit us against each other. The PCP thinks the specialists are evil, while the specialist is just trying to keep the last shred of payment left from the previous 20 years of cuts.



Anonymous said...

Our industries treat doctors as "providers" and airline pilots more or less as taxi drivers. It's no wonder that these two fields are perpetually in a slump.

There is an old saying that goes "if you pay peanuts, you get monkeys."

Bank and insurance company CEOs get bonuses in the millions, while PCPs countrywide struggle to bring home 75K a year. It's not difficult to see where our society's values and priorities dwell.

Jeffrey Parks MD FACS said...

Pelosi is a prime phony. This is not a revelation. Let her sweat out an independent review right next to Cheney.

Anonymous said...

AND her job seems easy, doesn't it Dr. Park?

"Speaker of the House" - just "speak on behalf of the house" - piece of cake!

YOU seem to be the one who underestimates the task - reform, with all the necessary politics, negotiations and compromises - at hand.

Politics isn't like surgery; you can't put the whole country on bypass machine or barbiturated coma and work on your changes.

Jeffrey Parks MD FACS said...

No one is arguing that it isn't difficult being Speaker of the House. The issue is the revelation that Ms Pelosi was informed of much of what was going on re: the Cheney torture regime from the very beginning, all the while acting "outraged" when the torture story broke this year.

Anonymous said...

Why in the world is he paying $100 a month for a medicine that is available for $4 a month? He can forward half the $1152 annual savings to me if he wants.

Also, you said it was controlled though just above that you said it trended down toward normal. So what was it? Controlled or uncontrolled? Trending toward normal is uncontrolled. Uncontrolled is seen fairly regularly until controlled.

Once controlled, assuming no other risk factors(and those have been screened for) and no symptoms than q6months and eventually qyear is fine.

Disability Insurance said...

I think a busy schedule is a must to stay profitable, however, I think one's health should come first. If you're not healthy than you have a tougher time earning an income. So physicians must find that health and profitability balance.

Anonymous said...

If Obama cannot reform our overall domestic programs and policies (from energy to education; from healthcare to defense), i don't see another politician or policymaker who can.

If we don't overhaul these systems over the next 4-8 years, we probably will never get another chance to before things start to get from bad to drastically worse.

In short, Obama and his team of infield and outfield advisors & fellow policymakers are the key players, whether we like it this way or not.

Do we need a reform? Hell yeah! Most of our regulatory policies haven't evolved since the end of Cold War; some redtapes can even be dated back to WW2 era's political landscape.