When it comes to health care in general and primary care in particular, America is not keeping pace with the rest of the world. Shocking as it may be, America is not in the top 30 countries in infant mortality and not in the top 40 in life expectancy at birth. We have a health system organized around acute care.
Those were the opening remarks of Dr. Harvey Fineberg, president of the Institute of Medicine, at a symposium – “Shock to the System: Preparing Primary Care for the Baby Boomers” – that marked the 30th anniversary of Urban Medical, a pioneer in providing patient-centered primary care to the frail elderly and chronically ill in Boston.
Currently, primary care is geared to treat acute, episodic problems in 15 minute patient visits. Fineberg said the team approach, as developed and practiced by Urban Medical, is a system of care that thinks first about the patients’ needs. He said “these understandings are not going to arise in the acute care setting.” And what we need to help solve the crisis in primary care, is to see a “thousand more Urban Medicals around the country.”
Unfortunately, the focus on acute care, “crowds out chronic disease management and preventive care,” according to Dr. Thomas Bodenheimer, of UCSF, and an expert on primary care.
But he also said that primary care, as currently organized and practiced is “not a job that is possible to do.” Studies have shown that 42 percent of primary care physicians say they don’t have adequate time in a 15-minute visit to really listen to the patient and 50 percent of patients say they leave a doctor’s office without understanding what the doctor said, Fineberg added. That is a recipe for bad outcomes all the way around – for the doctor and for the patient alike.
Add to that the critical shortage of primary care physicians that is expected to worsen as the baby boomers age. Nationally, the percentage of third-year residents choosing internal medicine has dropped precipitously from about 50 percent in 1998 to 20 percent in 2007.
So, what can be done? Bodenheimer says macro and micro level solutions should be implemented. For instance, on the macro level, health plans need to invest in primary care and recognize that follow up, care coordination and patient education take time. “All patients can’t be funneled into a 15-minute visit,” Bodenheimer said.
And on the micro or primary practice level, Bodenheimer says care must be redesigned around three areas: panel management (who is getting the care), care management (how that care is being delivered), and coaching (helping patients care for themselves).
Among his suggestions: Have someone in the doctor’s office other than the doctor responsible for managing the patient list…calling them…asking if they are taking their medications, etc.
For care management, Bodenheimer points to the Urban Medical model, in which a team of nurse practitioners, physicians, social workers and non-clinical care coordinators manages all of the patient’s health care needs at all times, through all settings. The team even makes house calls, because their goal is to avoid unnecessary hospitalization and trips to the emergency room and support aging in place.
With coaching, he says there needs to be a partnership between the patient and care team to teach patients and families the skills they need to help care for themselves.
Dr. Robert Master described how Commonwealth Care Alliance, by providing adequate resources to focus on primary care and care coordination, has demonstrated savings in hospitalization and overall costs for dual eligibles. Dr. Jeffrey Kang, the chief medical officer for Cigna Healthcare, acknowledges that for insurers the issue really is how to change the reimbursement system to create a “resource-based” fee system to pay for the “medical home” concept of care.
None of these is a silver bullet that taken alone will solve the problem of meeting the needs of aging baby boomers in a quality and cost effective way. But it is clear that primary care has an important role to play and that these ideas are an important a start toward laying out a roadmap for the future.
Secretary of Health and Human Services, Dr. JudyAnn Bigby and Billie Rosoff– who herself had a career in health care and now helps care for her husband, Arnold Rosoff, a House Calls patient of Urban Medical– closed the symposium with personal stories of the difference the patient-centered team approach can make for patient and family alike. “It’s just the most fabulous model. It works for people who have to be in their home or who need to be in their home,” said Rosoff.
Susan L. Kaufman
Executive Director, Urban Medical
Duh. We should be beyond this level of conversation on the topic by now.
“When it comes to health care in general and primary care in particular, America is not keeping pace with the rest of the world. Shocking as it may be, America is not in the top 30 countries in infant mortality and not in the top 40 in life expectancy at birth. We have a health system organized around acute care.”
Ms Kaufman, you left out the part about “We have a health system organized around PROFIT-DRIVEN care.” Acute care dominates because it generates more profit.
The greed that pervades the U.S. medical-industrial complex is bankrupting us all, as well as maiming and killing millions of Americans. Not your Urban Medical group but you cannot pretend to exist as an island. If you’re not part of working for a real solution than you’re a part of the problem. That goes for the politicians, especially.
Why won’t any of you “invited posters” talk about the elephant in the parlor on this issue? Tens of thousands of people are dying prematurely (after suffering a lot, I might add) EVERY SINGLE YEAR in the US because we allow health care to be treated as a commodity rather than as a public good. Because of this disgraceful fact we don’t have a national health insurance program!!
And we’re all being bankrupted (morally, as well as financially) by our dysfunctional, inequitable, and horribly expensive profit-driven system of health care.
It’s time Americans started losing their patience on this immoral issue and instead started getting outraged and then acting together to make changes in a targeted and effective way.
Please learn more and join this work at http://www.MassCare.org and on the national level at http://www.HealthCare-Now.org
Why isn’t there a shock to the system that people cannot afford medical insurance?The bubble will burst as people and business cannot support the greedy insurance companies so like the housing market it too will burst.Years ago corporations profit goals were in the millions,now it’s in the billions,whats next trillions?Well now that the cost of living is through the roof we’re broke and the well is dry,what’s next?
Addendum to my above angry communication:
I don’t want my prior remarks to obscure the fact that Urban Medical and its staff do indeed provide good and essential health care services to many in the community. I am many others are grateful for their existence and their commitment to caring for the community.
It remains appalling that programs such as Urban Medical are, by far, the exception rather than the standard available type of care for frail elders and others across our state and our nation. We must work together to remedy that situation as one part of our commitment to achieving fundamental health system reforms.
When asked why he robbed banks, Willie Sutton said, “Because that’s where the money is.” When we look at the often lopsided focus of our healthcare system, what drives hospitals to focus on the areas they do, e.g., we can’t overlook the fact that they are simply following Sutton’s law. Third party payers pay for acute care and specialty care and so that’s exactly what providers deliver.
In the 1990’s the sound byte was “it’s the economy, stupid.” Our healthcare system’s woes now reflect “it’s the reimbursement (and policies), stupid.” For example, third party payers, including government payers, don’t often reimburse for healthcare educators to be a part of practices to support primary care clinicians, yet educators, like all working individuals, expect to be paid for their services. And primary care clinicians struggle to cover the costs of running their practices, often not even receiving full reimbursement to cover the cost of vaccine purchase from insurers who are fully aware of this shortfall. To compensate for shrinking reimbursement, clinicians must increase the volume of patients seen. This leaves insufficient time for patient education. And it also leaves no money to cover the costs of educator salaries, absent third party reimbursement for such. But payers choose to not reimburse educators at a reasonable rate. Insurers often won’t cover the cost of nutrition visits until a patient is morbidly obese. So much for an ounce of prevention being worth a pound of cure! Meanwhile, hospitals focus on services often based on where the reimbursement dollars exist, rather than on where the community needs exist.
The invited blog said, “Follow up, care coordination and patient education take time. All patients can’t be funneled into a 15-minute visit.” The secret is that when patients wait an hour or more to be seen, it’s usually because insufficiently time-allotted and often one-size-fits-all visits collide with the realities of caring for patients. Those clinicians who refuse to ignore patient needs and so try to give the patient extra time despite not having it in their schedule end up running late. I recall a patient admitting to me that she changed to a doctor that was always on time because the doctor she originally saw always ran behind. Then, one day she needed more time than the 10 minute slot allotted for the visit because she was worried sick about her child. But at the 10 minute mark, the doctor strode out of the room and went on to the next patient. Suddenly, this woman realized why no one had to wait to see this doctor, and realized what she traded when she left the other doctor’s panel. It is unfortunate that this is the reality, because everyone loses. Nor does this reality make for a satisfying professional career, where thoughts of retirement never cross a physician’s mind—the experience of older physicians.
Administrators generally are ‘bottom-line’ people. As such, they often come up with suggestions such as ‘do 10 minute annual physicals’ as the solution to patient access problems, clearly not understanding what’s involved in performing high quality care, especially for those patients who have issues or chronic conditions. Access is not merely the act of getting the patient into (and out of) the exam room. Access is having adequate time to deal with the patients’ issues and to fulfill the ever-growing clinician’s tasks, many of which are part of ‘pay for performance.’ Again, this results in a collision, or trade-off. Do I as clinician focus on the patient’s concerns or on the pay for performance requirements that will assure I can cover my practice costs for this visit while not ending up with bad marks on the quality web site because I neglected items on the checklist when time was devoted to the patient’s concerns instead. The double bind is that I don’t have time for both. Speeding up the conveyor belt of office visits is not an effective way to improve access. It’s merely a way to give the impression that you’re improving access.
The National Conference of State Legislatures web pages on chronic disease demonstrate a huge void for Massachusetts. Namely, we have no chronic disease legislation or chronic disease requirements of insurers. Yet third party payers of all stripes know the same dismal fact…that those few with chronic disease consume the vast majority of healthcare expenditures. Massachusetts is no exception to this rule, yet Massachusetts has not thought about legislative policy to deal directly with this fact. Pitney Bowes knows from experience that savvy benefit design, despite increased short term costs, saves money in the long term. So it moved all asthma, diabetes and hypertension meds and supplies to formulary tier one, in some cases, distributed meds without costs to patients, used aggressive case-finding and case management, etc. and reduced its healthcare expenditures. It’s time to get smarter about policy and benefit design. Putting too much “skin in the game” when the average consumer’s skin is rapidly thinning due to the growing wage disparity, shrinking tax base and rising prices of necessary goods in the USA make many consumers highly price sensitive, may merely forestall patients getting necessary care early enough for the problem to be easier and less expensive to manage. This cost-shifting may give the impression that we are containing costs as healthcare service utilization declines. But delays may come at a higher price, long term. There is no silver bullet or spoonful of sugar to help the medicine go down when it comes to dealing with the complexities of our healthcare system and its costs.
From a societal perspective, the best thing we could do right now is to take money out of the health care system. We spend twice what other societies spend on health care and get worse results. I don’t think diet and exercise account for the different societal outcomes, but even if the American lifestyle is actually responsible for these statistics, then people need that time (that they are now spending paying for the health care system) back so they can get more rest and exercise. We have to prioritize, because money equates to people’s time and time is a finite resource. It comes down to whether the cost is worth the benefit and right now health care is not worth the high cost. And more importantly I doubt it could ever be worth such a high cost.