Mind & Body: The Future Of Primary Care In The U.S. Health System
http://thedianerehmshow.org/shows/2012-10-16/mind-body-future-primary-care-us-health-system
The U.S. is facing a critical lack of primary care physicians, and it’s likely the Affordable Care Act will worsen that shortage. Many worry there won’t be enough physicians to care for the estimated 30 million people set to gain insurance under the law in 2014. And it’s not just an issue of fewer doctors joining the ranks. While 20 percent of Americans live in rural areas, just 9 percent of physicians practice there. But some argue that the way primary care doctors practice is even more important than their numbers. This hour, the first of our new medical series, “Mind and Body,” Diane and her guests discuss the future of primary care medicine.
Guests
Elizabeth Wiley
national president of the American Medical Student Association
Julie Rovner
health policy correspondent for NPR and author of "Health Care Policy and Politics A-Z."
Dr. Fitzhugh Mullan
Murdock Head professor of medicine and health policy, George Washington University School of Public Health and Health Services.
Dr. Sumi Makkars Sexton
partner, Premier Primary Care Physicians in Arlington, Virginia. She is also assistant professor of family medicine at the Georgetown University School of Medicine and an associate editor for the journal "American Family Physician."
Comments
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Topic: Bored, Uncaring and Independently Wealthy Doctors?
During the Vice Presidential Debate, Congressman Ryan claimed 23 million will lose health insurance and the $716 billion "cuts" in Medicare will mean the Government payments will be so low that doctors will push away Medicare patients. Are doctors and other providers so independently wealthy that they can afford to dump patients en masse, assuming that doctors and other providers will want to? Will there not be enough money in the payments, under the Affordable Care Act, to insure patients get sufficient care and doctors get sufficient payment?
Sounds like Congressman Ryan is being the boogeyman that he was accusing the Vice President and President to be.
Is there something(s) that the Congressman was not on the level with -- again? Will the panel please detail and explain? And will Madame Defarge head a 15 member panel shouting "Off with the head?" Sounds just a bit mad, no?
Thank you.
I guess were still just pretending today that Obamacare will stand.
As the wheels come off this administration, it seems more appropriate to discuss which remnants of Obamacare we are going to be stuck with. For example, I know we are paying more to have "children" on their parents plan until 26 years of age, which by the way means they must have been toddlers until 10 and preexisting illnesses covered even if you decide to jump on a plan at the eleventh hour? People are already paying increased premiums in anticipation of Obamacare. Sixteen thousand IRS agents hired to enforce Obamacare tax laws, are these green jobs?. Quite frankly I don't know how big the mess is, I just know it's a mess. Fill us in?
Mailings to Medicare eligible folks show that premiums for Medigap insurance are rising for 2013. Medigap is that "Medicare Advantage" coverage that lost its federal support under ACA....i.e. the 716 billion.
BUT coverage and benefits really shot up in both Medicare itself and Medigap.....e.g. many new health screenings are free. The new emphasis has been shifted to early detection of potential illness and early modification to solve it. There is even new free STD counseling, screening, and prevention free........FYI the rate of infection of STDs is higher among the elderly than any group other than teenagers.
Codgers out on the prowl.
From the experiences I and others have had with the health care system in this country, we can only wonder if our health care system is becoming a very subtle form of population control. Something to think about.
But only for those who take the trouble to think.
Honest?Abe wrote: "many new health screenings are free." "There is even new free STD counseling, screening, and prevention free"
Please explain "FREE"? these services are donated by doctors at no charge to anyone!
Statman2 wrote:
"Topic: Bored, Uncaring and Independently Wealthy Doctors?"
I tried to change primary care doctor (I am of medicare age).
No small medical practice would take "new medicare patient." So, I am stuck with the two large University hospitals.
There is a reason why university hospitals can take a new medicare patient and a small medical practice cannot. If you deconstruct the flow of funds financing medical care, you find out that university hospitals receive funds from the federal government for training their medical students, they can use a significant portion of the tuition fees from their students to cover direct costs (medical school is more like an apprenticeship program so the direct cost of one additional student is zero or near zero), plus it does get a minimum reimbursement from Medicare to cover the cost of an intervention (whatever that intervention may be). Further, they have other sources of funds as well (alumni, grants, special programs for out-of-country patients paid for by foreign governments, etc...)
Doctors are confronted to extraordinarily high financial burdens. They must reimburse the astronomical cost of their studies, they must have malpractice insurance, they must cover their overhead (if they are on their own), they must invest in equipment, they must pay rent, etc... And, surprisingly, they must feed their families...
The cost of medical care in the US must reflect this reality.
@Statman2
Ryan is being intellectually dishonest. Part $716 billion is cut from overpriced Medicare Plus corporate welfare plans created under the Bush admin. Hospitals and other providers agreed to other cuts in hope of making up the difference in gaining more insured patients. More people will be insured presumably via income based subsidized health insurance.
One of the greatest solutions to the primary care crisis we are facing and will only exacerbate is through the use of Advanced Practiced Nurses (APNs). APN's advanced educations and experience more than qualify them to safely deliver high quality, safe primary health care autonomously. But the American Medical Association (AMA) has consistently maintainted their stronghold as the gatekeepers to health care by their powerful lobbying efforts and deep pockets. Not only does the AMA not want to share the keys to the health provider gates, they do not want the eyes of the American Nurses Association (ANA) through their nurses who are trained to be patient advocates and maintain absolute integrity to monitor their behavior and practices. Currently the standard for APN education is the doctorate level, but only a handful of states allow autonomous practice.
seems this would help to create new jobs
If you are in a lower income bracket, your best source of dental care may also be the local university. Students need clinical experience in order to graduate so they are more willing to take on "marginal" patients.
Does the Affordable Care Act improve payments to primary care physicians over the current Medicare or Medicaid payments? A number if physicians have for years not taken those patients because of the low reimbursements.
I am a 32 year old mother of 2 small children, and have several health problems. Rheumatoid Arthritis, fibromyalgia, chronic anemia, thyroid problems. I have an internal medicine doctor, rheumatologist, hematologist, ENT, and see all of them regularly. I feel at times that I do not receive the care I am wanting, because there is a breakdownin communication between them all. Frequently I am told conflicting information, and given different opinions. Is this a common problem? Is there training in doctor to doctor communication, and if not do you believe that there should be?
part-insane politics,
Here in the US and in most English speaking locales, "free" means without charges.
Under the ACA and the private insurers that means no copays, no deductibles to be met, no caps lifetime or otherwise, not even coinsurance or coordination of benefits considered.
Under the former "managed care" policies there was an attempt to encourage patients to always go through their PCP primary care physician to get lower charges for typical services and specialist referrals: the accompanying practices included more screening and counseling on the basis of knowing more about each patient. The seemingly newer approach is more carrot than stick in order to encourage even more patients to be proactive and more educated about their own health over time and get treatment earlier and more often......BEFORE emergent conditions occur.....the EXPENSIVE ones to treat.
Key Health used to routinely deny claims by diabetics for proper footgear.....but pay high cost claims for amputations.......pennywise but pound foolish, not to mention the degradation of quality of life and future health. (People without feet cannot walk/jog to lose weight etc.)
Nurse Practitioners and Physicians Assistants can be used to supplement a well run family practice. Much of this work is routine. Please check needs in specialties such as cardiothoracic surgeons - residency training is doubled and pay for surgery is lower - there are and will be shortages much more egregious and difficult to cover.
I started out as a tertiary care subspecialist (neonatal-perinatal medicine) then after 15 years transitioned back to primary care pediatrics for family reasons. It was an excellent decision and I do not regret it, however, I took an enormous pay cut and have not and will not reach the level of compensation I had as a specialist. Primary care physicians, especially those in rural areas, will face low levels of compensation, well below the level of their urban or specialist peers. This is bound to be discouraging to new doctors after years and years of education and training and while carrying debt burdens from college and medical school.
Deatonfamily4 wrote:
"I am a 32 year old mother of 2 small children, and have several health problems. Rheumatoid Arthritis, fibromyalgia, chronic anemia, thyroid problems. I have an internal medicine doctor, rheumatologist, hematologist, ENT, and see all of them regularly. I feel at times that I do not receive the care I am wanting, because there is a breakdownin communication between them all. Frequently I am told conflicting information, and given different opinions. Is this a common problem? Is there training in doctor to doctor communication, and if not do you believe that there should be?"
I am in relatively good health... But I had an accident in 2011 which required surgery at a rather prestigious university hospital. I had a similar experience. The various specialties did not communicate effectively with each other; they also found it difficult to provide post procedures communication to patient (this would be me).
It is an essential issue which is addressed elsewhere with electronic records and a "carte vitale" (a life record card that the patient carries along when he visits any physician)
katherine620 wrote:
I started out as a tertiary care subspecialist (neonatal-perinatal medicine) then after 15 years transitioned back to primary care pediatrics for family reasons. It was an excellent decision and I do not regret it, however, I took an enormous pay cut and have not and will not reach the level of compensation I had as a specialist. Primary care physicians, especially those in rural areas, will face low levels of compensation, well below the level of their urban or specialist peers. This is bound to be discouraging to new doctors after years and years of education and training and while carrying debt burdens from college and medical school.
Absolutely... This is a significant issue when one considers the cost of medical training...
For perspective, check out the newspapers in the classifieds. The most jobs there (a tiny tip of the jobs ice berg) are for health care people......especially nurses and nurse practioners. Even the TV ads emphasize local schools pushing health care related training. There is a significant market for health care training at all levels. A visit to a clinic or physicians office reveals the increase of health care assistants, nurse practitioners, etc. to supplement the knowledge and hands on care.
College students regardless of career plans do well to consider adding health care related classes or even career changes to respond to the booming market. Classes in German literature are interesting; but classes in medical technology of all kinds offer real jobs and income for the long term. Even accounting classes in hospital finance and administration offer profitable alternatives, not to mention engineering in medical devices.
HonestAbe wrote:
"part-insane politics,
Here in the US and in most English speaking locales, "free" means without charges."
With all due respect, I frequently try to dissect Partisan Politics's opinions and fail to understand his points.
However, there are lots of services that are presented as "free" but aren't. The true cost is simply transferred unto someone else. These are called negative externalities. The cost of pollution, for instance, is transferred from the producer unto future generations or unto the government.
So, free prevention is paid by someone. Nothing is ever really free... Sorry!
Can you and your panel discuss the impact that international medical graduates can have on the shortage of primary care physicians? Are there not benefits to having foreign-trained doctors added to the medical system instead of spending to train non-physicians? I am a foreign medical graduate, and find there is a continuing stigma against their acceptance into the medical training system in the United States.
Thanks,
Ed in Miami
I am a practice administrator of a Patient Centered Medical Home
practice, NCQA level 3 designation and successfully attested to Meaningful Use.
This discussion must include the Primary Care physicians committment to
providing continuing and comprehensive care by disease prevention and health promotion for all patients.
Primary Care Physicians are Family/Internal Medicine, Pediatrics, Geriatric
and OBGYN. There is NO "General Practice." These physicians have 3 year
residencies, continuing medical education and Board Certifications.
The physicians are the "thinkers" of medicine. By close listening, preventive screenings, lab tesing...they develop the diagnosis, and guide the patient thru the processes.
I am surprised one of your PCP's on the panel, emphasised PCP's
discuss with the patient and decide how to proceed..,this cannot happen without a diagnosis. These relations with PCP's are the most trusting and intmitate that patients have.
I go to a Family practice physician that I wave to in the hall. He has 2 or 3 Nurse practitioners who handle my health care need for the most part. I am a Healthy 69 year old. My mother who is 89 years old has a Geriatrician is her health care home. When she had a life threatening arhythmia, Because of the electronic record she had her pacemaker within 3 hours, her primary physician handles her diabetes, her oncologist is linked to the system which seems to be seamless. It is very efficient.
If you want to be impressed, blown away, amazed, and encouraged, get an appointment at one of the advanced medical providers......e.g. Mayo Clinic, Cleveland Clinic et al.
The interaction of knowledgeable providers of various specialties and subspecialties along with integrated technology and interchange of up-to-the-moment results among the professionals and paraprofessionals is truly wonderful. Even the scheduling of appointments compressed into a short span of days via electronic means is impressive. Consider that kind of situation with spreading out multiple appointments over weeks and months via uncoordinated providers who have barriers to shared information......the difference is astounding.
The future should be directed to outcomes and CARE rather than fee for service.
I'm concerned about this focus on primary care for seniors. As the daughter of a parent with diverse complex medical issues, I've called every practice in Irving, Texas, and none are accepting Medicare patients. I love the quarterback idea, but try to find one.
In the UK pcps are highly regarded & I think earn more than specialists.The idea is to prevent rather than fix. Makes alot of sense to me. Love you & your show.
As a Physician for more than 30 years in primary care, It is clear to me that the
system is broken and too expensive. It is not rational to add ANPs, PAs and let
them practice primary care in a poorly supervised or unsupervised situation, but this is the
plan for the future it seems. The same old problems are rehashed endlessly since
I was in Med School with no solution in sight. Until we go to a single payer system
that takes the insurance companies out of the huge overhead of medicine and
control the specialists who run up costs, it will not get cheaper or better. We must
model our system on those of Canada or EU to get a handle on things. We need
primary care Internal Medicine Physicians to care for the chronically ill elderly, and
FP doctors to care for the less complicated patients, and they must be induced to go
to rural towns where these people live, but it is very difficult to do with poor schools
and poor infrastructure in rural areas. Good luck with this.
Ferdnam,
With all due respect, when costs overall are lowered, the net effect is to offset high cost services with lower cost consultative screenings.....which can often be done by less expensive staff. A trained clerk can run a treadmill test and provide results to a doctor. A tech can extract blood andvrun it through test machines with results reviewed by a physician. Every time a task is done by technology or non-physicians the costs are lowered....as long as the doc ends up managing overall care. New policies often include no-charge limited memberships at exercise facilities e.g. YMCAs et al. Anybody knows even slow walking at a local mall improves overall health. It costs nothing but patient time to walk in a safe location.
Even auto dealers offer low cost lube jobs and inspections in order to obviate more costly repairs and inconvenient situations for drivers.
Costs are pushing forward not to other patients........like has been going in for years due to uninsured patients, especially going to the ER (the Romney Room).
Deatonfamily4wrote: "I am a 32 year old mother of 2 small children, and have several health problems. Rheumatoid Arthritis, fibromyalgia, chronic anemia, thyroid problems. I have an internal medicine doctor, rheumatologist, hematologist, ENT, and see all of them regularly. I feel at times that I do not receive the care I am wanting, because there is a breakdownin communication between them all. Frequently I am told conflicting information, and given different opinions. Is this a common problem? Is there training in doctor to doctor communication, and if not do you believe that there should be?"
What is your diet like? I've been doing much research, and have come to a conclusion that many health problems in our modern society today is narrowed down to the diet. We are told that we have to eat low fat, low cholesterol, encourage to use artificial sweetners (i.e. Equal--which actually derived from a chemical used in warfare, Splenda) and the like. Has it occured that eating a diet that the government and the health "experts" tell us to eat that we are getting sicker and fatter? When people were eating traditional diets before all of the mechanization that people were healthier. If I may suggest, check out "Real Food" by Nina Planck as well as The Weston A Price Foundation. These are very interesting resources and may shed a light on things diet-related.
I am a firm believer that our diets have a huge effect on our health. Why is it that with all our modern technological advances in health care that people aren't getting any better? We are told that we are to eat low-fat, low-calorie, low-sugar, and to consume sweetners like Equal and Splenda as opposed to sugar. In addition many of the foods we deem nutritious are not because they are laden with pesticides and chemicals. When you buy a tomato from the grocery store, it's picked when its still green for ease of travel--as it travels approximately 2,000 miles to get to one's plate. In addition, once it arrives, it's treated with ethylene gas to ripen it--EXTRA ethylene--as it gives off the gas naturally. This is done so that it makes it "look" ripe when it's actually not. When you eat a peach or a strawberry from the grocery store (which is part of "the dirty dozen"), it is laden with pesticides. When you buy meat from the grocery store, it comes from a feedlot--in which the animals are mistreated and are given chemicals and antibiotics to either keep them "healthy" or to make them fatter...quicker for market. All of the experimentation, mechanization, and chemicalization is making us sick, and the government subsidizes such companies! The biggest blow is the commodity crops that are GMO's that are found in ALL processed foods--which, again, its subsidized by the government.
Part 2
The Farm Bill--which is reviewed every 5 years, is the major culprit in the subsidizing of these huge agribusiness--which is producing food that are making us sicker and fatter. Think about all of the food recalls within the last several years (i.e cantelope, peanut butter, tomatoes, spinach). This is due to the runoff from the factory farms producing meat. The runoff is a result of these huge manure lagoons--which contains bacteria like salmonella and eColi--which leech into the groundwater, and into the crops. It's recalled, the government comes in and says that the food is safe, but nothing else was done to prevent this from happening again. Our regulatory companies have no backbone, and we the people are paying the price. I'd might also add that foods are produced cheaper to our wallets, but it's more expensive to our health. The consumption of industrialized, processed foods are the culprits to the many health problems today. Think about it, why do you think that in a time when processed foods were virtually non-existant or in cultures today who still hold to their cultural, old-school diets with no processed food that there are no or lesser cases of diabetes, heart disease, cancer, and obesity?