Thursday, July 30, 2009

More Riffs on Health-Care

Everyone is talking about the need for change in the health-care system but the system is constantly changing. It is a huge enterprise responsive to many factors ranging from economics to new scientific discoveries and developments to new illnesses making sudden appearances to changes in personal views on life and death. Some changes have been taking place with relatively little notice from the public. One big shift is the movement by many hospitals to employ hospitalists to care for hospitalized patients. Hospitalists are physicians trained in internal medicine with particular focus on the needs of hospitalized patients. These, of course, tend to be the sickest individuals and require the most time and attention. What this means for you, the "customer" is that your primary care provider will care for you when you are well , have a relatively minor illness or when you have illnesses that are chronic and generally not severe. When you get really sick and have to be hospitalized your primary care provider, most often your "family doctor," will not be the one caring for you. Someone who probably has never met you before and who has a number of sick patients to care for will be in charge of your medical management. On the positive side, you will be taken care of by someone who keeps up-to-date on the management of serious illnesses and who is being paid to take the time to care for you. They are not in a rush to get back to the office to get through a busy office schedule. They are responsible to the hospital and also responsible for providing information about your condition to your primary care provider. Therefore, their management is closely scrutinized and if they do not meet the high standards generally set, they have to find another job. On the down side, the medical professional who knows you best and who you feel most comfortable with is not the one who will be taking care of you when you are at your most vulnerable and want to know that the person caring for you knows you well and cares deeply about your well-being. The truth is that most primary care physicians would like to take care of you when you are really sick in the hospital but they just can not afford to do so. The system has dictated that in order to be able to stay in business and make a living (and we are not talking about a fortune) primary care providers need to see many patients in a day. There is just not enough compensation for the time physicians spend in the hospital caring of one,two or three hospitalized patients. Taking care of two hospitalized patients can easily take a couple of hours and in that time the doctor could see six or more patients in the office. The hospital is able to bill for the services of the hospitalists they employ and pay these physicians a reasonable salary. Of course, the large teaching hospitals utilize residents as hospitalists and they have been a source of cheap labor for many years but as residency work hours are restricted, hospitals have to employ more expensive health-care providers including physician extenders such as physician's assistants and nurse practitioners. As sicker individuals are being cared for by hospital-employed personnel, primary care physicians spend more of their time providing well care and managing chronic illnesses. Much of this type of medical management can be handled by physician extenders who command lower salaries than physicians. By expanding on this army of health-care providers and leaving physicians to oversee these health-care providers and directly manage the care of more complex problems that specialists generally manage we can hold down the number of primary care physicians needed and keep health-care costs from rising further. If we want the highest quality of care for the money, we will want more specialists and more physician extenders, not more primary care doctors. This is how I see it , from my perch.

Sunday, July 12, 2009

The Future of Medicine as Perceived by a Working Neurosurgeon

Health-care reform has taken center stage in the national political debate in America. In truth, it has been center stage for years. I recall when I completed my residency in neurosurgery in Washington, D.C. in 1984 the talk was all about the escalating and out-of-control health-care costs. Government had to control medicare costs, limiting expenditures with the assistance and complicity of physicians. The government gained support of physicians by a monetery redistribution, taking money form "proceduralists" who were the minority and giving more to "cognitive" specialists, physicians in the majority. In other words, they took money from surgeons and gave more to internists, general practioners and the like. In the end, of course, everyone got less. The "cognitive" specialists had to see many more patients to make ends meet and the "proceduralists" could never make enough with the reimbursements the government provides. In the end, private insurance had to subsidize the medicare system to keep "proceduralists" in the medicare program. Surgeons, unless they are employed by a hospital, make their living from private insurance reimbursement. If the government begins to provide a medicare-type insurance policy to the currently uninsured at reimbursement rates similar to medicare rates, "proceduralists" will drop like flies. They will simply be unable to remain in business. The truth is that we already have a shortage of "proceduralists" and we will have a major crisis in access to care if the number of "proceduralists" drops further. As the population grows and ages, more people require craniotomies for subdural evacuations, hip and knee replacements, laminectomies, thoracotomies, abdominal operations, prostectomies, organ transplants, mastectomies, colonoscopies, arterial stenting procedures, etc, etc.. Though much is being spoken of primary care shortages, the solution lies not in more primary care physicians but in more physicians extenders. It does not make fiscal sense to pay highly trained physicians to provide well-patient care. In truth, one physician can oversee several nurse practioners and physician assistants. These physician extenders can provide care for many routine medical problems ranging from colds to diabetes management. More complex disorders which require more expertise and more time can then be managed by internists and medical specialists such as cardiologists, neurologists, endocrinologists, oncologists and the list keeps expanding because medicine keeps becoming more complex as more is learned about each medical disorder and treatments become more refined and diverse. It has become nearly impossible for one physician to know all the crucial management issues for every medical disorder. Furthermore, individuals are becoming more involved in their health-care and as information becomes more abundant on the internet, the majority of Americans will be playing a significant role in their health-care. In fact, patients may be required to become more active in "doctoring" themselves. It will improve the quality of health-care and save a substantial amount of money. Patients will be required to fill out forms on-line that ask questions about their medical history and symptoms of illness. Based on these answers a differential diagnosis will be generated. Patients can then review these diagnoses to understand more about their illness and also review possible treatments. When they then go to their health-care provider a differential diagnosis will already have been generated saving the health professional a considerable amount of time. It will also reduce errors of diagnosis and treatment because the health-care provider can choose a treatment course based on the recommendations the program generates. If the treatment plan does not match an option, the health professional will need to provide a justification/explanation for why they have choosen this particular approach over another. The patient can review the treatment plan to whatever depth they wish in order to feel comfortable with the plan that has been recommended. In the end, the quality will have been maximized. This type of program could be created now (and probably is being created by some clever health-care organization) and patients who are willing to complete it before seeing their health-care provider should be offered a discount since they are saving their health-care professional and the health-care system time and, as they say, time is money. More ruminations on health-care to come.