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.

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