Saturday, May 23, 2009

Health Care Reform (5) - and stories in the exam room

On my American Academy of Pediatrics listserve, one contributor recently said, hey you guys, how come everyone is talking about minutiae, when the biggest deal of our professional lifetimes, a real point of inflection, is coming down the pike? I took this as an invitation an came up with the following post.

The endpoint of the post is that not a whole lot is wrong with primary care pediatrics in the current system that enhancing pay would not cure. There are lots of other things that can be done, but most all of them are curable by money and some regulations - for instance, maybe the Medical Home concept could be pushed and paid for and better and more efficient ways of following chronic disease could be fostered. But we don't have to do anything fancy.

I would also now add this: it's important to distinguish pediatrics and adult care. There are significant difficulties with adult care, some of which have led to the Retail Based Clinic movement. That is, adult primary care practices are relatively insensitive to urgent patient needs. A pediatric urgent call will result in a same day visit; and adult call will result in a later in the week visit, which is not responsive to the problem and the patient, really.

There was a recent article by two Harvard B School professors proposing (yet again) that more midlevel practitioners be used for "simple" primary care problems, and extensive work-up protocols in Electronic Medical Records be used by primaries to extend their reach into what are currently specialty areas. Problem with this - this is not where the problem lies! (See below).

Also, it is true that we have to wonder if our current primary care system uses very extensively trained clinicians for quite mundane problems, and can we afford this, and is it wise, especially since other countries don't do this much with pediatrics, although they do with primary care in general. Answer - yes, it is wise and yes we can.

Here's my answer. One day last week I had three patients in my truncated afternoon schedule. The first was an infant of a new mother who had been my own patient as a child. She is 20 years old, African-American, and brought the father of the baby with her. She has turned into a quite mature young woman. She doesn't get the support she hoped for from her own mother, and she and the father are not together any more. But she said that she had asked the father to come to the doctor with her because she wanted him to be part of her baby's life. She remembered that her own mother had often been angry at her father and had prevented him from coming to the house and seeing his daughter. She didn't want that replicated. Somehow, this routine visit was elevated in her mind to an important family event. I was ever so flattered and tried to live up to her expectations by asking the right questions, encouraging both mother and father, etc. Could a midlevel have done this? Maybe. But not the way I could, I'd say. And I come cheap, I'm primary care.

The second patient was a 14 year old boy I was seeing in followup, with his mother. He is a marijuana user and seller, is with the wrong crowd, is recently failing in school although he is sufficiently bright, his father is an alcoholic, and his mother moved out of the house some months ago. Tension is rife, his younger sister is following his mother's lead and rejecting the father. What is this boy to do, and what am I to do with him? I support the mother as I see them together, I help him think about his summer and positive things to do when he will be in a cast since he has a non-junction healing fibular fracture that needs an operation, and then with him alone I talk with him about how he is doing. I tell him that his job is to keep himself together, and that this is the best thing he can do for his family. I am his friend and support. His mother tells me that he will only come to see me, that he rejects other counselors. What do I do that's so special? I don't know, but I've known him for a long time, and her, and somehow I have meaning to them. I hang in there with them. And I'm not very expensive.

The third patient was a two year old son of two physicians who has been slow to walk and slow to talk. We have identified both problems and elected not to do much with either. I think we referred him to ortho for the walking problem, "just to be sure," and I think I recommended a little speech and language action just to juice up the development. He's coming along OK. My chief contribution, again, is support. They trust me as someone who has seen a lot of kids. Because of their relative sophistication, I think they need to relate to a doctor, not a midlevel. And again, my chief attribute is not to panic and to watch and wait and support. And again - I'm cheap!

I have to tell you also that as a doctor these three cases each give me enormous satisfaction. I think I can help each one of them, each in a different way. And I think I bring my total life experience to bear on each case, and try to understand them as fully as a I can. The smarter I am, the better they have it. I'm not going to be replaced by a midlevel or a computer protocol anytime soon.

So, in this super-long post - sorry - here is what I wrote about health care reform, in response to the post by pediatrician Mike Kuduk:

>>Mike, thanks so much for your recent postings and your help in keeping the list serve up to date. I agree, this epochal reform deserve our full attention.

You wondered in your previous post if any of us had ideas as to where our interests lay here. At the level of generality of the current negotiations, it might be hard to tell, and we don't know what the actual points are under negotiation, except for what is publicly available. I suppose some of our governmental relations people know to some extent - maybe - but I understand that this ever-changing data would not necessarily be shared with us, since we are not the governmental relations or finance committees. So, it's hard for us to know what is exactly at stake specifically for us.

Some things should be evident, however. The "drunk under the street lights" phenomenon will be at work, as it always is. (I meant to post on this in relation to the Yahoo comments from the Harvard B-School guys the other day, but now I can't find it.) That is, it is so easy to attack primary care. Hey, just raise the deductible, just lower the RBRVS or don't raise it, just insist on current Medicare rates and no higher, just reimburse vaccines at actual straight purchase price cost and you have absolutely stripped primary care pediatrics bare. It's easy to do!! The problem is, this this not the problem. Primary care pediatrics is easy to attack, but this is not the source of high medical care costs -- just the opposite. But like the drunk, it's tempting to find a fix here to a problem that doesn't exist.

Where does the problem exist? Insurance costs and overhead - everyone recognizes this, and just deleting the cost of underwriting will help some of this. Fighting with providers not to pay them, this costs money to the system, to employ all the no-saying clerks, but I am sure non-payment save them money. Of course it costs the whole system money, since the public's money is already in the coffers and its just a question of distribution, to the providers or to the insurance companies, so it is a systematic cost. One way to deal with this is just pay and don't negotiate - the Medicare way, I guess. But that is pretty draconian. So I don't see an immediate fix for this in altering the behavior of insurance companies. The main fix will be in reducing underwriting, I guess. Wish I knew more about this.

Specialists cost a lot to the system, in what they take and what they order. Again, how will this be fixed? A Commission of Effective Practices? I don't think this is the major problem, actually - it is the "work it up until every possible thing has been done" syndrome. There are two basic ways to attack this problem - regulate what procedures work and which won't work (back surgery), or give new incentives, which might work. But it's very hard to capitate, which would be the "incentives" approach. The Dartmouth solution - give the money in a DRG way to a hospital and affiliated physicians for each incident of illness - has been and will be rejected by docs. So, I really don't know how they will rein the specialists in. They should, but it seems hard to do.

Pharma costs a lot - I'm sure there will be some savings there with competitive bidding.

Hospitals - now to my mind, this is the biggest drain on the system, just look at bills and look around you on rounds for what people are doing and not doing and look at the exorbitant staffing at the administrative level, yet we hear almost nothing about these costs. In the past virtually nothing has worked and it's amazing to me how little we hear about reining in hospital costs in the current proposals. These institutions just consolidate and charge and plead penury while gobbling up more and more and economizing not at all. There is a lot in the literature about how lots can be done - see the Intermountain experience - but that the savings in the past have been passed on to insurance and the institutions that have done the savings just see their payments decline. That sounds pretty familiar. I hope some real solutions will come here, but I haven't noticed any.

Primary Care Pediatrics

OK - so what I'm saying is that reform needs to go where the big money and the big problems are, and primary care needs to be nurtured. Seems to me that this needs to be our mantra. Search in the shadows where the money and waste are, not under the street light where primary care lies bleeding!

There have been some proposals that the Feds need to mandate that Medicaid payments meet a national standard, and that some states (like California, for instance) cannot drop so low as they are. That is something we should get behind.

It looks like, surprisingly to me, that there may actually come into being a BGP (Big Government Plan) that will compete with the private plans. It will be funded only by premiums similar to other plans, which is only fair. It will have to be regulated further. Russell and others have been rightly suspicious on this listserve that it will provide un-negotiable provisions, and will use monopoly tactics to drive the private plans out of operation. I yield to no one in my suspicion of governmental operations, and the ability of government to be as undeferential as the worst Commie government practices we have heard about. But - if government sees the need for primary care, would it be possible that they would lead the way with large payments to primaries, so that we made it up to the standard of the British NHS, say? If so, and if the BGP were to capture a large portion of subscribers, wouldn't the private plans have to compete to get us to join their networks? What if the BGP paid us 125% of AWP for vaccines? (I know, dream on.)

So, that's where I'm coming down on what is in our interest. It is widely understood now that primary care is very important for our medical care system, and that it is failing, and that poor payments won't support a decent income. The BGP will need to be regulated. Therefore, part of our governmental efforts will need to be to make the BGP regs favor primary care pediatrics. Nothing fancy, just high payments, low copays and deducibles for primary care, and none at all for kids. Let the fancy stuff be applied to the insurance companies, pharma, hospitals, and specialists. Show me the money.

Please excuse my going on and on. Blame Kuduk.<<

Budd Shenkin


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