(+3 rating, 3 votes)
Loading ...Whoa. The sabers are rattling.
In an opinion piece , Dr Jonathan Glauser (who works at the Cleveland Clinic) lashes out against primary care. His belief is that funding primary care is a mistake because it is “a group that has failed in providing care.” His argument is one you will hear a lot from specialty organizations and hospitals, so I will address it head-on.
Here is what he says:
The patient-centered medical home is an approach to providing comprehensive primary care for children and adults. This is touted as facilitating partnerships between individual patients and their personal physicians and, when appropriate, the patient’s family. This is the brainchild of a consortium of organizations, including the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. These worthy groups claim to represent approximately 330,000 physicians….
I should mention that the concept is not new; it was introduced by the American Academy of Pediatrics in 1967. It’s on all patient-centered medical home web pages. Obviously, these organizations will be pressing for funding to promote their ideas of primary care. They want money, money that might go to other elements of our flagging health care system.
Say what? Fund physicians to promote primary care? Why throw good money after bad? If ever there was a group that has failed in providing care, it is our primary care system. To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars.
This guy is not arguing, he is ranting. Why? My suspicion is that he sees the fact that increased reimbursement for primary care physicians means potentially decreased reimbursement for emergency physicians. That does not mean you shouldn’t trust his arguments – he could use the same against me. So his main point is this: primary care gives nothing of value and so should not be funded. Funding primary care is a waste of money.
How does he back up this attack on my profession? First, he gives examples of bad primary care he has seen. I can give plenty more examples of bad primary care…and bad cardiology, bad surgery, and bad emergency medicine. There are bad physicians out there – we all know that – but the bad physicians don’t mean that the whole profession is bad.
He goes on as follows:
I have never encountered a plea for health care reform that did not extol the benefits of detection and treatment before some disastrous outcome ensues. In the long run, of course, preventive care does not save society money; we all get some terminal illness eventually. But it does enhance the quality of life we have if we can go though our days without aphasia, hemiparesis, or an ejection fraction of 20%. Where is it in the plan that everyone gets a doctor regardless of ability to pay? Clearly, the uninsured, the working poor, and the people currently without access to care would benefit most from such a program. What happens to the patient-centered medical home when the patient can’t pay?
Much of the degeneration of primary care in this country, in fairness, is not due to these doctors themselves. After all, their office visits have been booked solid for months. They get paid for seeing 25 patients (or 20 or 30) a day, so they and their office staff can knock off at 4:30 p.m. Any appointment they see on February 26 was booked in November. They never see anyone who is acutely sick so it wouldn’t even make sense to add an appointment on as an emergency.
I think the points here are as follows:
- Prevention is good, but does not save money.
- It may be worth it, as it improves quality of life.
- The problems with primary care are caused by appointments not being available.
So what do I think about these arguments? Prevention in the general public may not save money – at least in the short-term. Yet preventive medicine does not just occur in healthy populations – it is far more cost-effective in people with medical conditions. For instance, preventing heart disease in diabetics (who are high-risk) – even if it is simply making sure they take aspirin – saves money and lives. There are a large number of preventions for high-risk patients that would have a quick return on investment.
The opinion piece degenerates from her, saying:
- Primary care doctors don’t see acute illnesses, but send them to the ER.
- Pediatricians shouldn’t take care of fever, because it could be serious problems that require lots of lab tests/x-rays.
- Primary care physicians “can’t manage simple chronic illness, cannot definitively treat acute illness or injury, often has no skills to save lives and no access to equipment if he had the skills, and does not even see patients at their own (the customers’) convenience”
- Medical home involves doing things that just require computer systems and can be done by anyone.
- Primary care doctors can’t “differentiate splenomegaly from lymphoma or a direct from an indirect hernia suspect”
- Primary care is a “sham” and putting money toward it would be equivalent of throwing the money away.
- Surgeons, dermatologists, and orthopedists are bad too.
I could go through each point and argue them, but they are honestly so silly that I think most of my readers see this is nothing more than a rant. It offers no solutions, just a shotgun blast at his colleagues – insulting their competence. It got my blood pressure up, and I would ask my reasonable Emergency Medicine colleagues to protest such rancorous slander from one of their own.
Still, there are lessons to be learned from this:
- There are some really angry doctors out there. Any time people are fighting over their share of money, you see their worst. This is a prime example of it. This physician sees (probably correctly) that increased money for poorly-paid primary care physicians will have to come from somewhere – and that somewhere will probably be from decreased specialist reimbursement.
- There are many physicians out there who don’t respect primary care. They seem to think that we do our job because we couldn’t get into “better” specialties. I think my job is much harder than that of most specialists. I have to know the range of disease – from newborn to geriatric – and be able to identify the seriously ill ones from the long line of people who have common ailments. I refer to specialists 5-10% of the time.
Any reform will be met with stiff resistance. The likely result will be watered-down solutions. A medical home may work if done correctly; a medical dog house probably won’t. Reform needs to re-form medicine; not just rearrange things without substantial change.- Denial is well-entrenched. This physician spends a lot of time pointing fingers time with no alternative solutions offered. He is complaining about the wallpaper on the Titanic as it sinks. I don’t think the medical home is perfect, but screaming seldom fixes things.
- We really need the Obama administration to get good people. Shrill voices like Dr. Glauser will doom healthcare reform and turn our profession into a bunch of children fighting on the playground. I am very thankful that the emergency medicine bloggers I know are much more grown-up.
Emergency Medicine News should edit more carefully.
This is destructive ranting at its worst.
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{ 16 comments }
Wow! What anger. We’d be in bad shape without our PCP.
I don’t even know what else to say except I’m glad I’m not his patient.
Hmm … I have to wonder where he gets care for himself?
It’s a turf war, or better known as territorialism that we inherit from our four-legged ancestors.
Our health care will soon be overwhelmed via an shortage of PCP, and such renting gives us a better insight into “why” and why our system is so resistant to change. Ugly, indeed….
Oops, r-a-nting i mean!
The “MBA” after Dr. Glausers name tells me all I need to know about him. I know his type, wears Crocs and a Starched White Coat with his name in Cursive above the pocket. But when his Crocs hit the Tile he turfs as much as anyone. If Cleveland wasn’t such a miserable place in Winter I’d go up there with my Hypertension and Reflux and Bitch-Slap him when he admitted me to the Medicine Service. Of course he probably only sees 1 or 2 patients a shift, since he’s busy doin all that Teachin’. And not to name names, but Emergency Medicine isn’t really a “Specialty” either, its why they grandfathered a bunch of FPs GPs and Internists when it started back in the 70’s.
As an emergency physician and editorial board member of EMN, Dr. Rob, I agree with you.
As PA, I’m pretty sick of writing the admissions (10 forms) for these sorts of cases. The patient has KNOWN HTN, DM, edema, COPD…and suddenly they need to be admitted for what? More of their home medication! A single unit of blood! ONE bag of IV Abx! A single dose of VItamin K???
You may dislike the writer and his phrasing, but a significant proportion of hospital admissions are just ridiculous.
Hey Steven Davidson, M.D., Guess you’re not credentialed to write E-mails, since it took you 2 attempts to say nothing, hope your Chest Tube technique isn’t as bad. And Kristi, those Lame Admissions??? Spring a Pair, and DON’T ADMIT THEM!! or tell whatever Physician you’re Assisting not to Admit Them, afterall, YOU’RE the one with the Residency/Fellowship behind you, oh yeah, you don’t, anyway, treat them yourself and send em’ home if you’re so MFin smart.
OK, I’m takin 2 e-mails to make a point too, but thats cause I’m Intubating some poor guy an Emergency Medicine Specialist pushed 10mg of Vecuronium on, Hmm whats the ICD code for Saving an ER docs nutsack????? Oh yeah, No ones gonna take you seriously if you call yourself “Kristi” just say you’re “Dr” whoever, and just mumble if they ask where you did Med School/Residency…
The idea of medical home came out in 1967? I recall my Mom bragging about our great GP, Dr. Gaebe in 1960. I grew up with a medical home; our doctor. My in-laws, who grew up in the same small town went to the same medical practice their entire lives until the last guy retired. They had a tough time finding a new medical home in their sixties.
There is a lot of the population that never goes to the emergency room. That poor guy has never seen the successes that are acheived in primary care clinics.
Everyone has a right to a rant now and then. But two things really shock me about this. One, that it was actually published in a print version of an emergency medicine news magazine (though I’m pretty sure it’s one of those throw-aways we all get). Two, that he’s an assistant professor at Case Western. How embarrassing for them. I hope he doesn’t teach medical students.
The reality cuts both ways. When I had my initial flare of Crohn’s and severe abdominal pain coupled with diarrhea that suddenly stopped, I was kicked out of the ER so the physician on duty could take the dead woman from the ambulance and write her death certificate. Medicare had a better reimbursement.
But there have also been times when I’ve been to the ER and they worked with my doctors. They called them, or paged them with questions, and helped. When doctors work together, the patient usually ends up better off. A patient who ends up better off is a patient who is more likely to be able to pay their co-payment.
I believe reforms need to be four pronged:
1. Eliminate the access gap. A large part of the ER problem is because GPs won’t accept uninsured patients without up-front payments. Things like the three year old with severe asthma which wasn’t diagnosed until he was in the stall next to me in a small rural ER in California wouldn’t happen if his family had insurance. Universal access means incentives for doctors to accept whatever public plan that passes. Loan forgiveness, or tax credits for those without loans, are a good way to make that appealing.
2. Remove insurance industry profit from the system. Most of Europe–especially Germany and Switzerland, which track well with our system–eliminated that incentive when they passed universal reforms. Simply put, there will be unjust denials, doctors will get left holding the bag, and everybody else’s fees will go up with we keep it up with the $1.6 billion compensation packages for insurance CEOs. Worse, rewarding executives with stock options means that there is pressure to increase profit. That means that they will institute policies that cause unnecessary denials in the hopes of upping the stock price.
3. Reduce tort and improve disciplinary procedures actions. When I had a surgery, I signed a piece of paper which said I knew death was a risk of the procedure. Yet when people die in operations, or when fetuses die in c-sections, there is a rush to blame somebody. But the surgeon could’ve used all proper methods, and due to a person’s anatomy made an incision that turned fatal. Automatic suing upon deaths needs to be eliminated. Some sort of Tort reform where the first step in a lawsuit is a peer review should be instituted. And for the bad doctors who give the wrong drugs to patients: there should be no cap. Likewise, if a doctor is continually making the same mistake, their license should be revoked. Also, there should be an age limit on the practice of medicine. I think medicine fails to recognize that skills decline as people age. We stop pilots from flying at 65, judges from judging at 70, and yet there are surgeons in their 70s and 80s who operate. And doctors in their 80s–I know one with heart disease who is 84–who still practice. Why?
4. An honest discussion about end of life issues. I am a relative of a patient with end-stage Alzheimer’s. There is no reason what so ever to put her on a feeding tube. Yet other patients in that nursing home with a similar disease are on feeding tubes. And they sleep 23 hours a day in a nursing home, wasting away so family members can come by once a week and visit their living, breathing grave site. This wastes a ton of money, as nursing homes are about $45,000 per year, which is picked up by Medicaid after the person’s assets run dry. And the feeding tube causes them to live 3-5 years longer than they should. But this is also about radical chemotherapy for terminally ill cancer patients, Remicade for terminally ill Crohn’s patients, and dialysis for terminally ill kidney patients among others. We have to accept that doctors are not miracle workers. And that they have limitations, and that sometimes the end result isn’t what we’d like.
If we do those things, we can reform the system in a positive direction. Whether the President-elect does that or not is an open question. I worked hard for his campaign, but there have been mixed signals coming out of his administration. On the one hand, he says it’s a priority, and they’re trying to fire up their network for it (which indicates that they want to test how much they can count on citizen lobbying). On the other hand, the incoming Secretary of Health and Human Services is advocating letting states be “laboratories of innovation.” That’s Washington Code for: We’re gonna punt.
Hear, hear! Along the same line, people tend to behave differently (if not selfishly) when either greed or excessive fear is in the equation. Unrealistic as it may sound, it’s better for patients and doctors alike if we leave money and politics out of the equation when it comes to patient care and medicine.
This is an embarrassment to both the writer, ERP’s, and the publisher. Please note that this is not the feelings of most ERMD’s. While yes there are problems with some PCP’s it is the minority, not the majority.
Kristi, you have no room to talk, suck it up and fill out the paperwork. If it bothers you that much to have to use a pen, find another job.
We really have to question the judgment of Lisa Hoffman, editor of Emergency Medicine News (e-mail: EMN@lww.com). Glauser obviously has a personality disorder and wouldn’t last any time in private practice.
His views read like something out of the parody news site TheOnion.com and we can be fairly sure that while Glauser may be an excellent physician — I emphasize MAY; the lack of studies or journal articles in his tirade do not reflect those of a doctor who appears to have done even cursory research into the subject upon which he expounds — it is likely he not well-respected or taken too seriously by too many of his colleagues.
Lisa Hoffman, on the other hand, should have took one look at this purely anecdotal, adolescent fit of an op-ed, smiled, shook her head in disbelief, and loaded it promptly into the paper shredder.
Our Paraplegic Health Care System That Now Exists In The U.S.
Regarding PCPs, I offer the following are facts that are believed to exist regarding the present U.S. Health Care System. This may be why about 80 percent of U.S. citizens understandably want our health care system overhauled:
The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
However, the U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care cost presently is over 2 trillion dollars of our gross domestic product. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
We have around 50 million citizens without any health insurance, which may cause about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children, which alone covers about 7 million kids.
Our children
Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage is largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits to a damaging degree.
About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA, according to others.
Our health care we offer citizens is the present system is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported, which should be addressed as well.
It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. This specialty makes nearly 100 thousand less in income compared with other physician specialties, yet they are and have been the backbone of the U.S. health care system. PCPs manage the chronically ill patients, who would benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly have of the population has at least one chronic illness- with many of those having more than one of these types of illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget. .
The shortage of primary care physicians is due to numerous variables, such as administrative hassles that are quite vexing for these doctors, along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients. Many PCPs are retiring early, and most medical school graduates do not strive to become this specialty for obvious reasons. In fact, the number entering family practice residencies has decreased by half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers.
Yet if primary care physicians were increased in number with the populations they serve and are dedicated to their welfare. Studies have shown that mortality rates would decrease due to increased patient outcomes if this increase were to occur. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if numbered correctly to serve more, the quality improves, as well as the outcomes for their patients. Most importantly, the quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase in the years to come. The American College of Physicians believes that a patient centered national health care workforce policy is needed to address these issues that would ideally restructure the payment policies that exist presently with primary care physicians.
Further vexing is that it is quite apparent that we have some greedy health care corporations that take advantage of our health care system. Over a billion dollars was recovered for Medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations who deliberately ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy, so it seems.
Health 2.0, a new healthcare social networking innovation, is informing patients about their symptoms and potential if not possessing various disease states- largely based on the testimonies of other people on various websites. This may be an example of how so many others rely now on health concerns from those who likely are not medical specialists, instead of becoming a participant, if not victim, of the U.S. Health Care System.
Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up this system as it exists today, which is why the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens, it appears. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals, potentially. It should be and likely will be funded by a combination of payroll taxes and general tax revenue:
Access- citizens do not have the right or ability to make use of this system as we should.
Efficiency- this system strives on creating much waste and expense as it possibly can.
Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
Sustainability- We as citizens cannot continue to keep our health care system in as it is designed at this time- as it exists today.
http://www.mckinsey.com/mgi/publications/US_healthcare/index.asp
Dan Abshear
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