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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The Demise of Primary Care

David Norenberg has written a brillant article on the causes of the demise of primary care. He proposes one of the best solutions by suggesting that Medicare pay salaries to primary care physicians and thereby allow them to practice medicine as it should be practiced - free of the intrusions of managed care. See his article at www.annals.org in the May 19th issue of the Annals of Internal Medicine Vol 150. p 725, 2009.

In a subsequent posting, I will trace the great harm and added expense that the demise of primary care has brought to the American public.




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Present state of American medicine

In my first entry I traced the history of medical care since WWII. I ended with a statement that we had arrived at a state of excessive use and errors and harm. Before we can proceed in our analysis of what and how the system went so wrong, we need to get more specific about what is wrong with American medicine.

So here is a list, in no order, of the problems. I am not documenting the sources but if challenged for accuracy, I believe I could dig up the sources.

First, let's look at our major strength. We are a rescue system. Get in a car wreck and your chances are best in the world to survive. Have a heart attack, and you will receive the best care in the world. Get a life threatening illness and American medicine will pull you through better than anyone.

Beyond these rescues from death, we are not very good. We are very expensive, we exclude almost 15% of our citizens from ordinary care, and we do a lot of harm in our hospitals. So here are some details.

We spend nearly 17% of our GDP
Our per capita expenditure is the highest in the civilized world.
We are the worst in what is called "amenable deaths" in the developed world (France is the best at preventing preventable deaths, we are the worst)
Our life expectancy is among the lowest in the developed world
We have one of the world's highest infant mortality rates in the developed world
Our prevalence of diabetes and obesity is one of the highest
We have around 100,000 preventable deaths per year in our hospitals.
In the last 6 months of life, we spend a large amount of Medicare dollars on futile care
(by futile care, I mean care that only extends the period of dying)
Our per capita expenses range from $4000 in one region to around $7500 in another region
The quality of care in Medicare is inverse to the dollars spent. It is best in the low expense regions and worst in the high expense regions.
The use of surgical procedures is highly variable from one small region to another, with no visible reason for the variation other than the capacity for the procedure.
Mortality rates for prodecures in hospitals are variable and range to unacceptable high levels in some.

American medicine is the only enterprise where competition has driven up costs and driven down quality.
The American public has no information on which to decide where to go for care.

Hospitals should be required to post their procedure and major disease mortality rates, their infection rates, complication rate, and the number of each procedure done annually. Until the public can have that information, it cannot make a rational choice of where they go for care.

If a can of food is required to carry a label of its contents, then something as potentially dangerous as a hospital should be required to post its contents and outcomes.

Medicare has the data on the hospitals it pays. They should publish the outcomes by hospital.






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Ideas for reducing costs of healhcare -joining the debate

I write from the perspective of a physician who has followed the curve of excess costs from the days (1950s) when there was very little money in medicine. On my first posting, I trace the sequence of events that led to the present state of high costs, large variations in use, and large errors and harm.

WHAT TO DO? HERE IS A STARTER SUGGESTION:

Medicare has clinical and cost data across the country. Why not use it to curb futile and unnecessary costs?

1.Track hospital mortality rates for costly procedures and drop hospitals who exceed the death rates by a certain margin. There are still hospitals for excessive mortality in many areas. Drop them from medicare for those procedures.

2.There are many hospitals doing procedures that are too small in number to be good at the procedures. There is a minimum number of operations that need to be done; below that number it is unsafe. Drop those small volume hospitals from medicare for those procedures.

3. The huge amount of money spent in the last 6 months of life can be curbed. Define what is futile care in the elderly (I am in that age group and do not want futile care) and refuse to reimburse futile efforts.

4. Move patients who are receiving futile care into hospice and palliative care.



These suggestions would save money but will need congressional backing. Medicare already has the data. USE IT! This will save money and improve the overal health of the population.

This blog will contain writings from mutiple authors and physicians

Follow this blog for writings from many well known physicians who are concerned about the present state of American medicine.

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A brief history of American medicine and its excesses

Chronolocially:

• WW II showed the value of science in medicine.
• NIH funding started slow but then accelerated to astronomical sums
• Human biological and medical science grew
• Medical school faculties expanded to huge sizes with NIH funding
• Many sciences were completed (anatomy, the vascular bed, renal function, heart function, joint functions and others)
• A completed science becomes engineering and technology (Kuhn, Structure of a Scientific Revolution)
• New technologies emerge in rapid pace
• Medicare is cost plus funded with capital pass through for construction
• Wall Street discovers hospitals and investments for the first time
• For profit hospitals appear
• Wall Street funding funds technology developments
• Medicine becomes a business of doing more and more
• Businesses demand growth
• More and more procedures must be done to feed mega business
• Medical practice and patient care suffer from the excesses and inappropriate use of technologies
• This is the curent state of high cost, error prone medical care