Thursday, May 28, 2009

The Demise of Primary Care and the False Positive Problem

The demise of primary care is a large part of the increasing cost of health care in America. The story is a bit complicated so follow closely. It goes like this:

At first contact between the public and medical care, most of the problems presented by the public seeking care are psychological or psychosocial in nature. Studies have shown that between 50 and 70 percent of initial physical symptoms are driven by psychological or social problems. Stress produces physical symptoms in the body. These problems can run the gamut of human behaviors from marital discord to problems at work to problems with children to financial worries and on and on down a long list of stresses and worries. The good primary care physician knows to listen and attend to these problems and at the same time to attend to the physical symptoms so as not to miss any medical disease of the body. In most cases the symptoms due to stress are eased by appropriate counseling. Only when clearly indicated does the primary care physician begin to order more intensive diagnostic tests.

This careful approach to the use of complex tests allows the probability of serious disease to increase before the test is ordered. By careful listening and doing this, the good primary care physician is avoiding the false positive problem. If instead or watching and waiting a bit, the physician jumps to complex testing, there will be a huge number of fasle postive results requiring more complex testing and then more complex testing and on and on until the false positive problem is resolved by extensive and some times dangerous tests. All of this will cost large amounts of money. Much of this can be avoided when a patient has a strong and trusting relationship with a good primary care physician who knows the patient as a person and knows how to listen and sort out the problems with the patient.

If instead of a primary care physician, the person goes directly to a specialist who is not tuned to the psychological and social nature of much of primary care then the chances of a false positive result increase greatly. The specialist too often moves into complex testing too early . And the costs go up proportionally and dramatically.

The demise of primary care needs to be reversed. Much of the high cost of medical care comes from the depletion of primary care physicians who know how to listen to their patients.

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1 comment:

  1. True, true.

    But this has been a recognized fact for over 15 years. Even with just about everyone now convinced that primary care is under compensated and the number of primary care physicians is dangerously low, congress is debating a 5% increase in reimbursement to primary care over the course of 5 years.

    The insurance plans at the same time are squeezing more out of primary care with this year a 99213 visit being priced below $40 and deductibles being increased with the doctor being responsible for chasing down payments.

    Woopidee doo. I will take home less than last year, which was less than the year before, this year it will just be offset a little.

    All of you like that medical assistant, receptionist or office manager in your physician's office? Good chance that they will be replaced this year because:
    1) Primary care phsycians cannot afford to take deeper paycuts by offering raises and so they go to work for a specialist who can easily pay them 40 to 50% more.
    2) Primary care physicians will cut down on the health insurance or other benefits in order to remain profitable. Medical assistant will leave since she needs the haealth insurance.
    3) Primary care physician will fire more staff, cut office hours and stay home as much as possible
    4) rimary care physcian will close down his practice and go see shoes (not kidding).