Monday, December 15, 2008

Primary care has no value?

So says Dr. Jonathan Glauser, an emergency physician and MBA. Writing in Emergency Medical News about proposals to increase funding for primary care, Dr. Glauser had this to say:

"To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars."

Oh, there's more. "How could we as physicians ever allow a doctor to call himself primary care when he can't manage simple chronic illness; cannot definitively treat acute illness or injury; often has no skills to save lives and no access to equipment if he had the skills; and does not even see patients at their own (the customers') convenience?"

And this: "Their unparalleled record of failure and complete dispensability does not merit even a second thought of throwing dollars their way."

Complete dispensability and no value to society? To put it as kindly as I can, it appears that Dr. Glauser didn't do his homework.

If he had, he would have known about the hundred-plus studies, annotated by ACP, which show that primary care is consistently associated with better outcomes and lower cost of care.

He would have known from our review that "states with higher ratios of primary care physicians to population have better health outcomes, including decreased mortality from cancer, heart disease, or stroke; individuals living in states with a higher ratio of primary care physicians to population are more likely to report good health than those living in states with a lower ratio; and the supply of primary care physicians is also associated with an increase in life span."

He would have known that "an increase of just one primary care physician per 100,000 population reduces ER visits by 10.9 percent."

The ranting of one emergency room doctor might not be worthy of comment, except I wonder how many other ER physicians share his distorted and uninformed view of primary care.

ACP plans to send a response to Emergency Medical News. You can help us by posting a response to today's blog. The most interesting comments are likely to be quoted (with your permission) by ACP.

Today's question: How would you respond to Glauser's view that primary care (and by implication, general internal medicine) is "singularly inept at performing anything of value to society, is pure folly and a waste of precious health care dollars?"


Jay Larson MD said...

There are only two sorts of doctors: those who practice with their brains, and those who practice with their tongues.

The greater the ignorance the greater the dogmatism.

Sir William Osler

Arrogance and ignorance are co-morbid conditions. Therefore, an arrogant doctor is very dogmatic.

Dr. Jonathan Glauser appears to be having a bad week. Is medical professionalism totally dead? Does Dr. Glauser plan to do all the follow up after a patient has seen him in the ER? Will he manage their depression, their diabetes, their lung disease, their hypertension, their osteoarhtritis, their osteoporosis, their heart failure, their kidney stones, their gout, their hyperlipidemia, or their gastroesophageal reflux disease? Will he do it well enough to qualify for a P4P bonus? I know that my fellow internists can not only manage simple chronic illness but also complex chronic illness.

For those doubters out there that do not feel that there is a primary care crisis nor do they understand the benefit of primary care... keep it up and you will see what it takes to be a general internist because there won't be internists around to do the job.

Paul said...

The Patient Centered Primary Care Collaborative would agree with you. We are a Collaborative of over 400 organizations large employers physician groups, healthcare benefit companies and consumer groups. Study after countless study shows that when a patient has a primary care physician that cares about them has and uses the tools to practice comprehensive care centered on the patient needs they get the care they need at a price we can afford. Let's call that a Patient Centered Primary Care (PCPC) or Patient Centered Medical Home (PCMH).

But we the buyers large companies have been part of the problem (as Pogo said so long ago I see the enemy it is us) in not demanding systems of payment and practice organization that encourage and enable the comprehensive, patient-focused primary care we desire. There is no money paid for the necessary investments in teams and health information systems so essential to the delivery of comprehensive, cost-effective, patient-centered care. Current payment methods richly reward medical procedures and discourage spending time with patients in such essential activities as history taking, physical examination, diagnosis, planning treatment, counseling, coordination, and prevention. This must change. ,

When one compares the U.S. health care system with those of other industrialized countries, one is led to the more specific conclusion that the two major problems in U.S. health care are the way we 1) fail to deliver comprehensive primary care and 2) the way primary care is financed. Our premise is that primary care is the only natural locus of control of health care quality and costs. It is the only entity that is charged with the longitudinal care of the patient. It is the only entity whose job it is to consider the whole patient, the health of the whole person, including mental and physical.

For some reason, the healthcare industry and we as the buyer have demonstrated an inability to develop a sharp focus on solving core problems. We seem much more willing to create complicated responses to our problems than we are to fix the core problems of our delivery system. Again, disease management is a perfect example. If primary care is not delivering high quality care for those with chronic conditions, we can either find a way to work around primary care or we can find a way to fix it. Our willingness as large employers to "pay any price” for that episodic care which for example provides for a Diabetic amputation of a limb but our unwillingness to open our eyes and understand that the reason for the amputation was our failure to be willing to pay for the prevention and primary care.

Demand of ourselves as patients, employers or physicians for our patients or profession and our families:

Comprehensive, continuous, patient centered primary care which is based on strong relationships between patients and their physician -- this is foundational to good health. Practice and payment reform are the prescriptions for achieving it.

The lack of our ability to arrive at this because it is not aligned with what we pay for in healthcare is the root of the problem.

gladtohelp said...

It's not just this loon.

See the above ACEP position on the PCMH. It's basically all well and good (with some distractions and straw-man arguments like #8) until you stop and think about why they're so wedded to #5. Why would the ACEP want to prevent "soft gatekeeping" by the PCMH (a wonderful term coined by some very smart folks at the Center for Studying Health System Change).

It's because non-emergencies (and minor emergencies) are incredibly lucrative for EDs! Billings for, say, a sore throat are astronomical in the ED, especially if you throw in a CT. We all know non-emergent acute care is a cakewalk for most docs (and NPs, as Minuteclinic proves every day). The ACEP is simply scared that effective PCMHs will appropriately keep patients _without_ actual emergencies out of the ED. This would be good for patients and good for society, but bad for the ED bottom line.

I suspect more specialty groups will line up against the PCMH. High-quality primary care which integrates and coordinates evidence-based care across the entire medical system has a good chance of reducing the volume of needless, duplicative, and harmful procedures and imaging tests.

Remember: every dollar of medical waste is somebody's income.

PCP said...

Those are the sort of idiotic remarks that emerge from a practitioner who becomes self absorbed and thoroughly ignorant of the challenges in outpatient practice today.
Payers have created a twisted situation where non acute illness patched up in the ER gets reimbursed perhaps an order of magnitude higher than a competent service provided by a qualified primary care practitioner. Such arrogance and rants are the inevitable result.
I blame none but the AMA appointed RBRVU committee and the reimbursement system they have hatched, and then the payment policies of Insurance industry along with ridiculously restrictive stark laws that limit the type and extent of services that can be provided in a primary care office.
My goodness, how the coming battles over distribution of scant resources will bring out the worst in some of our specialty colleagues.
The ugliness is sad. The jury has spoken on the importance of physician led primary care. The evidence is there and well encapsulated in the recent paper by the ACP. Only a delusional or self absorbed individual will speak in such a manner, and only a throw away publication will print such uninformed opinion.

Tom Roberts M.D. said...

It is probably important for anyone interested in health care reform to understand that Dr. Glauser, although more strident than most, probably represents the majority view both within and outside of the profession. Most people do not understand that the vast majority of our medical dollar is spent taking care of people with chronic disease. They think that doing things to people is the same as taking care of people. Multiple studies, well documented in the recent ACP white paper, show that ongoing management of chronic illness by a functional primary care system is probably the only way that the U.S. can effectively control costs, improve quality and provide access. The paradigm espoused by Dr. Glauser and supported by not only the entrenched interests of the current system, but also by the media and the public, believes that episodic acute care supplied by high priced specialists and hospitals can “definitively treat” illness. These people and institutions are so blinded by their ability to provide and be paid well for these episodic, sophisticated and intensive interventions that they cannot see the burning need for coordinated, longitudinal medical care of chronic illness. Until we can shift that paradigm we will remain stuck in the current situation of rising costs, poor quality, and decreasing access.

Steve Lucas said...

As just a poor MBA in this discussion I have to look at the successful medical models available in other countries. While no model is perfect, we do see some common traits. The first is a primary care driven system. Call them gatekeepers, or any other name, we can see any number of countries providing universal coverage, at half of the cost to the US economy, with better outcomes.

I found the ER comment interesting. In my rust belt city both nonprofit hospitals heavily advertise their ER services. In the summer it is bruises and scrapes, in the winter it is colds and the flu. How did we ever survive without an ER visit for a cold?

The reality is we will see a shift in the medical delivery model in the US and, as in any change, there will be winners and losers. For the US consumer/patient this means a more available and tailored treatment program. For the US economy, this means a lower cost system that will include a larger number of people.

Steve Lucas

Unknown said...

David Mathis, RN

When a patient is acutely ill i.e. Flu, AGE etc. they cannot get an appointment. The patient is directed to the ER or treated with telephone prescription.

Anonymous said...

It depends. I have Crohn's Disease. When I had my first flare, I went to the emergency room. They took my temperature, didn't bother with a CT scan or X-Ray. They wanted me to produce a stool sample but after a week of diary I couldn't produce one. Then they sent me home, despite the fact that sudden changes in bowel habits is a symptom of toxic megacolon.

The ER doc was a quack who clearly thought I was faking my illness and was more interested in treating the dead elderly woman in came into my stall after me. Medicare had a better payout for processing the deceased woman's records, I guess. He's lucky I didn't actually have the life threatening conditions he didn't bother to check for. And apparently chronic illnesses aren't so simple to all "emergency room doctors."

I didn't get better, and called the GP the next day. I was seen same-day by my GP. He treated me for three weeks with antibiotics (Flagyl) with some success. Figuring it was an infection, we cold cut the antibiotics, and well the Crohn's came back with a vengeance. Two weeks later, I was referred to a specialist.

His office wasn't very good. I had acute illnesses, and they kept having two week waits. I eventually found a new doctor. There were three times when my temperature shot above 104 degrees, and each time my GI saw me on the same day, and got me into the CT scan place on the same day.

I could generalize on emergency room doctors because of the one person I saw at the beginning. I don't because the rest were quite good. I had a complication after a surgery, and the ER doctor I saw was great. He figured out what the problem was--I had too much acid due to the operation--and saved me a week in the hospital.

His name was Sam. He never would've wrote that article because he is a good physician. He actually contacted my GI and my surgeon, who was elsewhere, via pager to ask about my past before pawning me off on them.

Too often doctors get caught up in rank. The best doctors work together.

Lydia said...

I would hate to see what would happen to the author if primary care were to vanish altogether, since currently, most of my job is trying to keep sick outpatients in the best condition possible and optimize their quality of life, so that they can stay out of the emergency department and out of the hospital.

If we all were to vanish, opening the floodgates, it would be a tough situation in the Emergency Department indeed.

The medical home model is not a money grab, as the author sees it; rather, it's an effort to get away from the piecemeal, bean-counting payment model that has led practice after practice to close and that has driven many to an early retirement, leaving no one in its place.

The primary care doctors I know are an overcommitted bunch, trying hard to maintain relationships with patients, earn their trust from first visit through the end of their lives, practice safe and evidence-based care, and keep their heads above water, all while knowing that their work often goes unrecognized by the system, since it's not billed.

A late-night or early morning call from a frightened patient that ends in reassurance instead of an ED visit? Or a nursing home visit before the workday to avoid a hospitalization? Or maintaining frequent email touch with patients whose disease illness has recently flared for no reason, who want to hear from you as well as their subspecialists?

The 10-minute visit for patients on multiple medications doesn't work, not when it takes them the first 5 to get out of their chairs and down the hall to your office. We often just have to take the time they need, and then we stay late to make sure these patients know how to take their multiple medications safely and correctly. And that's before they have a problem, like new abdominal pain. And it's usually 3 new problems, at least, all that need to be explored by a careful history and physical.

So the medical home idea? Of course it's not new, but the new part may be extrication from the bean-counting payment structure that ensures the useless visit length that hobbles the care that can be given in a day.

And yes, things need to be done differently. But a money grab? There are a lot quicker ways to make a buck than health policy reform.

And I really, truly doubt that the author wants primary care to vanish. Then he will see ALL of our patients, and I mean ALL of them.

LynnB said...

I could send a list of horrifying, wasteful and dangerous things done because the ED docs were or are adrenaline junkies--that's why they picked emergency medicine. Every PCP office has every appt booked because there are no PCP's left. I am surprised more people don't sign up primary care , especially what I do, small town general internal med --leaving at 4:30 and never managing an acute or a chronic condition sounds great to me. I can't imagine what I did wrong to leave after 6 every single night, work more "shifts" than any ER doc would ever work and spend 5 weekend days a month on the darn EMR and not make enough to send my kids to their fisrt choice ,admittedly expensive colleges. Maybe I sould give up pregnant type 1 and 2 diabetics and stage 5 kidney disease, and inflammatory bowel disease, and non-operable coronary disease,and interstitial lung disease, and RA and pelvic fractures and anything else I think is beneath me . No procedures there, expensive meds , lots of visits ,I sure as heck would rather make the same money seeing an INR of 5 or a sore throat -those are 213, my patients are 214's , and you can see and maybe even document a lot more pertussis swabs in asymptomatic patients .
At a large academic center he will have the opportunity to have PCP's frightened to do what they are trained for, and specialists who are dangerous outside of their organ system and perhaps even outside their are of interest whether it be cystic fibrosis related pancreatitis or hyperthrphic cardiomyopathy without outflow obstruction. The only way the gluten enteropathy specialist can get out of dealing with a call "my wife took my BP and its 190/115" is to send the person to the ED . The only way the general internist can avoid the nephrologist raking him/her over the coals when the patient calls "my wife ...and its 190/115" is to send the patient to the ED . Perhaps only the PCP knows that the patient isn't taking their medication because they can't afford it.
Dr. Glauser, walk a mile in a PCP shoes and come back. The medical system is broken, and it isn't because PCP's are lazy or stupid -some are but so are some specialists. Sounds like the ED is the safety valve on the pressure cooker -- not a great place to be , but trust me thangs aren't so great inside the cooker either

K. Bates said...

One can only hope the Dr. Glauser never requires the services of the primary care physicans he seems to disrespect. I am waiting for the moment when a patient receives this type of care in the ED: 1. discussion of the patient's pain management plan and titration of pain medications for RA joint issues which would otherwise be debilitating, 2. management of hypertension in a patient on multiple antihypertensives, immunosuppressants and various other drugs, 3. diagnosis and treatment of the patient's proteinuria and adjustment of angiotension-renin system with medication adjustment, 4. detailed plan of dietary therapy and other discussion regarding patient's hyperlipidemia, 5. management of menopausal symptoms severe enough to limit patients sleep, which is contributing to overall fatigue,6. management of a hypothyroid patient who after several adjustments is finally at an appropriate level of thyroid replacement, 7. management of interactions of a list of 12 medications and several specialists, including a rheumatologist, cardiologist, endocrinologist, making sure that everyone knows exactly what is happening with the patient in between their visits.

Did I mention that this was just one patient of mine today?

I'll be waiting for the day that patients get that kind of "service" in the ED, but I won't hold my breath. This is my 6th year in practice, and I love what I do, despite clear knowledge that I work in a sphere of like minded individuals who give more than they get and never get the respect they deserve.

But if Dr. Glauser wants to travel a hundred or so miles south for a day, he's welcome to the stack of paperwork left for me at the end of the day....which my husband wishes was 4:30.

Dr Joe said...

Unbelievably irresponsible!! I'm disappointed that EM News and Case Western would support such jousting (the worthless art of criticism for the purpose of elevating your own position in the world) of this nature. I could write a book on the deficiencies of Emergency Medicine but prefer to take the higher road of keeping my mouth shut and striving to do the best I can do. Clauser might take Ghandi's advice: "You must be the change you wish to see in the world."