But having financial access to care is, although necessary, not sufficient. We need other changes in our health care system. For starters, we more primary care doctors and other providers, for another we need systems that encourage and reward quality of care, and we need to have everyone receive care that is need, no one receive care that is not needed, and have health, not profit, drive the system.
Unfortunately, this is not what we have. While a sensible health care system, such as that in most countries with better health outcomes than our own, is built on a broad base of primary care, with a much smaller number of subspecialists, and even less hospital (and even less tertiary care). Our system, or non-system as I have called it, is skewed toward high-technology, high intervention care, aimed at the top of the pyramid. Most of the resources are allocated there, and balanced on a relatively small number of primary care providers. As should be obvious, inverted pyramids are inherently unstable.
One reason for this inversion is the demand of people in the US, particularly those with good health insurance or lots of money, for more and more expensive, high-tech care. This follows from the general assumption that “if some is good, more is better”, and “if it costs more it must be better, and if it is better it is what I want” that pervades much of our culture. Unfortunately, those old saws are not true when it comes to health care. Frequently, less is better, and more is worse. This has increasingly been demonstrated with a number of ostensibly-preventive interventions that have been showed to both increase morbidity (because of false-positive tests that lead to dangerous but unnecessary intervention) and cost. These include PSA testing for prostate cancer (even the American Urological Association has come on board by not recommending this test for most men – AUA guidance cited in AAFP Smart Brief May 15, 2013; it should actually be for no men), mammography for breast cancer screening, and the never-had-any-justification-as-a-screening-test-in-asymptomatic-women pelvic exam (the part where the provider puts hands inside, as distinct from the Pap smear screening test for cancer of the cervix, Questioning the pelvic exam, by Jane Brody, New York Times, April 29, 2013).
Farther down the spectrum of health care interventions are the incredibly costly things we do to people at the end of their lives. Heroic things done that ultimately don’t make any positive difference, and often end up extending a poor quality of life, or have someone end their lives enduring continuous interventions, needle sticks, and harassment. Why do we do this? Maybe because we want it? Some of us do. A colleague relocated from Kansas to DC says that people in the East don’t seem to accept that people die; she feels it is less of an issue in the Midwest, where farmers are used to animals dying, but I don’t know. I see it here. And, indeed, it is an extension of the observation by Marion Stone, the fictional hero of Abraham Verghese’s “Cutting for Stone”, that, in comparison to Ethiopia where he grew up and went to medical school, Americans seem to think of death as optional. But, of course, it is not. Many Americans have come to realize that, and have advance directives limiting what is done to them. But some, or their families, keep bringing people whose bodies are trying to die, into the hospital where our interventional technology saves them – for the moment. Until the next admission, a month or a week or a day later. “We have created,” says an intensivist colleague, “a group of people who can only live in the ICU.”
But there is more. And that is that such high-tech, high-intervention, high-cost medicine makes money, for the doctors who do it and the hospitals that it takes place in. And, of course for the manufacturers of the devices that are used. This is why, in large part, we have a primary care/subspecialist imbalance, why the pyramid of health care is balanced on that knife-edge. If cardiac care makes the institution money, if cancer care or neurosurgery or orthopedics does, this is what those institutions want. These are the specialists that they will subsidize to be on their hospital staffs. These are the specialties in which teaching hospitals will voluntarily support residents and fellows, even if that creates an inappropriate mix of specialists for the community at large. I have often said that in medicine, unlike classical economics, supply drives demand as opposed to vice versa. But I have also said that, as insurers move to prospective payment, the former money-maker product lines become cost centers, and that primary care providers who can care for things themselves without lots of referrals will become profit centers.
There is already evidence that this financial situation is shifting. Health Leaders Media reports in a story by John Commins on May 20, 2013 that “A survey of hospital CFOs shows primary care physicians generated a combined average of $1,566,165 for their affiliated hospitals in the last year. Other specialties generated a combined annual average of $1,424,917, the lowest average in five years, data shows. Primary care physicians have emerged as key money makers for their affiliated hospitals and for the first time are generating more revenues on average than their specialist colleagues, a survey data from Merritt Hawkins (PDF) shows.” This has to be good for primary care doctors, and has to get the attention of both hospital administrators and subspecialists.
However, it may not necessarily be good for people’s health. I say this cautiously, because, as I think I have made clear above, I do not think that it is better to have more subspecialists doing more interventional procedures which do not improve the quality of life. But simply showing that primary care doctors generate more revenue for hospitals does not mean that things are that different; it may only mean that primary care doctors are referring more patients into hospitals for procedures. This is, in itself, not the goal.
There is a goal. The goal is improved health for the American (and all) people. The goal is everyone getting the care that they need that will benefit them, and no one getting care that will not benefit or might even harm them. The goal is the medical ethics principle of justice: that everyone has the same options for diagnosis and treatment open to them, based upon their disease and condition, and not their wealth. The goal is a society that provides the necessary basis for good health – food, housing, education.
We can achieve that goal. We have the resources. We just need the will.
Very well said.
PCMH is being hailed as the holy grail for resurrecting primary care, but I see little evidence that it will be that and my guy feeling is it may well instead be the death knell for it.
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