Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, April 06, 2010

Stating the Obvious

There's a question that keeps popping up all over the place when the obvious mismatch between the dearth of physicians practicing primary care and the upcoming flood of newly insured patients thanks to the recently passed health INSURANCE bill:
What's going to happen when all those people can't find a primary care doctor to take care of them?
It is usually stated rhetorically. On the rare occasions when someone tries to answer it, they come up with something obvious:
People will go to Emergency Rooms.
Non-heathcare types may understand that ER care is far more expensive than that provided in doctors' offices and clinics, but the downside to ER care for non-emergency problems goes beyond that. ER care is more expensive because the ER mindset ("Don't miss anything," as opposed to the primary care mindset, "Don't miss anything important") results in lots of unnecessary care: blood tests, CT scans and other x-rays, etc.

The other piece of this puzzle, rarely stated, is that many, many patients, perhaps the majority, will recognize that the ER is not the appropriate place to seek medical care for their longstanding problems even though they now have insurance. (ER docs won't believe this, because they only see the people who come to the ER. It's hard to believe that what you don't see really exists, and I can vouch for the fact that there are lots of reasonable patients out there who do NOT think to rush to the ER for every little thing.)

The problem is that in the absence of sufficient numbers of primary care physicians -- and with no mechanism to filter access to specialists -- patients will self-refer to specialty care. Again, to non-healthcare types, this doesn't seem to be much of a problem. The American perception is that specialty care is "better," presumably because it's "special". And this is a huge mistake.

Specialty training is designed to focus on "not missing anything," because in an ideal world, anyone who clearly has "nothing important" going on would never have darkened the specialists' doors in the first place. When their comprehensive approach is applied to an unfiltered population, their extensive (and expensive) workups are not only useless and time-consuming, but dangerous to low-risk patients who have no need of exposure to the risks of useless testing.

What's really going to happen when those 30 million newly insured patients can't find Primary physicians is that the specialists offices will explode! Everyone walking in off the street will get the full workup of whatever that specialty office has to offer. Then, when no answer is forthcoming, they will get shuffled onto the next specialist, and the next, and the next. By the time they finally get into my office, multiple thousands of unnecessary dollars will have been spent to rule out everything I could have told them they didn't have.

This is the real reason health care costs will explode under the new law.

What to do about it?

Perhaps if there were a requirement that newly insured patients' first encounter with a non-primary-care physician be treated differently from an actual referral, we could find a way to get specialists to reign in their natural inclination to rule out everything under the sun (and then refer to their other specialty friends, to rule out everything else). I'm not sure precisely how this would work, but make no mistake: if something isn't done to address this issue specifically, the unintended consequence of insurance coverage expansion will be a surge in health care expenditures of unimaginable proportions.


At Tue Apr 06, 10:07:00 AM, Blogger Unknown said...

You're falling into your own trap there... there aren't going to be another 30M people with health care, just 30M people with health insurance. I'm sure that most of those people went to some doctor if they were sick enough that they would rather have health care than spare cash. The only difference for those people is that they will now be forced to pay for health insurance. Health insurance isn't a magical fount of money, it just spreads risk and adds administrative overhead, meaning that absent something rare and expensive, it will cost more than paying for it without insurance. So for those 30M people, they will no longer have the choice of balancing quality against cost, but will be left with balancing quality against... nothing. If you're paying $X per month, every month, whether you see a doctor or not, and every doctor costs a $20 co-pay, no matter how good or bad he or she is, then there's no reason not to go with the highest quality available (therein lies the rub - the only remaining useful metric becomes availability), and there's no reason not to do so every time you feel more than $20 worth of sick. Actually, probably more often than that, as there's the psychological pressure of wanting to "get something" for the money spent on insurance.

So actually, I do agree with your assessment, but I think that a significant chunk will be expressed in terms of family physicians seeing their previously-uninsured patients more often, but also some (at least near-term) losses by low-cost physicians.

At Tue Apr 06, 10:14:00 AM, Blogger RoseHelene said...

Which is why I'm seriously considering going into primary care myself. I wonder if more pre-med students will think like me as time goes on?

At Tue Apr 06, 12:36:00 PM, Anonymous Anonymous said...

Other problems with people self-referring to specialists:

1. People will self-refer to the specialist they think they need, not the specialist they actually need. If they have a stomachache, for example, they may self-refer to gastronenterologist when they may be better off going to a psychiatrist.

Primary care physicians, with their broad medical knowledge and also knowledge of the patient, is more likely to refer the patient to the right specialist.

2. Often times patients have complex combinations of ailments or conditions. They need someone to manage all of them, and that's not something a specialist can do.

At Tue Apr 06, 02:06:00 PM, Anonymous Anonymous said...

I haven't read anything about increases in self-referrals to specialists, but Massachusetts saw an increase in ER visits after our mandatory health insurance law passed.

Of course anyone who joins an HMO isn't going to be covered for self-referrals to specialists.

At Tue Apr 06, 03:21:00 PM, Blogger Pink said...

Or there is the flip side. We've been going to our FP doctor here in town for over 8 years now. He used to have just one NP working with/for him, but he now has 3 other NPs.

It's hard to get an appt. with him. So, for the following complaints, we have been referred out by the NPs:
1. Small sebaceous cyst on my daughter's scalp - derm.
2. Complaint of slight SOB while riding horse (daughter) - pulm.
3. Flare-ups of sciatica for a couple of months (me) - pain clinic.
4. Daughter thrown by horse and was sore 2 days later - physical therapy/rehab.

WTF? I don't want to traipse around to 10 different doctors for every minor issue!!! I know I should probably change offices, but we live in a really small town. Plus, I really LIKE the supervising physician!!

So, what's your take on the roles that FNP, NP, and PAs will or will not play in the specialty scenario?

At Tue Apr 06, 04:26:00 PM, Anonymous Anonymous said...

What Mira said.

Supply-and-demand will eventually work this out. There will be more need for primary care docs -- existing primary care docs will get more work -- more med students will find the primary care field appealing b/c it's more in demand.... It will probably take a few years to shake out, but I have confidence that it will, eventually, result in greater demand for, and utilization of, primary care docs.

Semi-related-thought: I really have to dig out my two junior papers and my senior thesis, all of which were on some aspect of the economics of health care (IIRC, one was on the effect of requiring second opinions before non-emergency surgery, and one was on the effect of different levels of co-pays on the amount of medical care used) to see if I said anything particulary prescient.

In any event, I think the health INSURANCE reform will, ultimately, prove to have a salutory effect on the bottom line of primary care practices. (Something I don't particularly care to debate, but would rather wait-and-see if I'm right or wrong.)


Kensington MD

At Wed Apr 07, 02:03:00 AM, Blogger Geoff said...

Self referral to specialists doesn't occur in Australia because the higher government rebate paid for specialist consultations is only paid if there is a referral from a GP. You could in theory self refer but as specialists charge a lot more than GPs the gap payment is prohibitive and patients are well enough trained to get a referral.

This works reasonably well although it does create the occasional useless consultation to do the annual referral to the specialist when everyone knows it is reasonable. On the other hand it means that specialist's skills are only applied as needed rather than for something that we GPs can handle.

We still have a problem here in that too many young doctors are opting for specialty rather than general medicine, but the structure of payment through the government insurer ensures that GPs act as gatekeepers and reduce costs.

It sounds like what a HMO in America would demand as well. Is that likely to be applied more generally in the American system?

At Wed Apr 07, 02:18:00 AM, Anonymous Anonymous said...

I honestly don't understand the concept of the whole going to the ER just because you have insurance (not Medicae/Medicaid, but honest to goodness insurance) & thus the worry that insuring more people will increase the ER flow.

My family has been insured for 30 years & one or the other has been to the ER for a total of 5 visits. All but one was covered becuse the incident resulting in the physical ailment could have affected life or viability of a limb.

The one that wasn't covered was for a flare up my husband's sciatica such that he couldn't walk. We paid the full price & we were young & learned what insurance will & will not pay for. So, unless it involves lots of blood, broken bones which don't happen during business hours or middle of the night heart ailments....we don't go since we then pay cash.

Far too expensive

At Wed Apr 07, 06:20:00 AM, Anonymous Anonymous said...

As per Australia, we in the UK cannot self refer to a specialist, referrals are done through ones GP or family Dr/primary care physician. As a result, as a child I never saw a paediatrician, as an adult I have never seen a gynaecologist because my GP would have treated most things and anything he/she considered beyond his / her remit would have been passed on to a specialist.
Then we come to insurance. Let's face it, insurance companies are there to make money! My only dealings are with medical travel insurance companies but mention the fact that you might be travelling to the United States and you have a pre existing medical condition and many European medical insurance companies will not even entertain insuring you! I paid in excess of $450 for three weeks cover to the US for just one pre existing medical condition. Why?
because should I have chest pains whilst in the US the travel insurance companies know I would be subject to a battery of unnecessary tests, angiogram, ECGs etc etc seen by cardiology specialists etc whilst I know that most of it would be unnecessary and costly. I have my own rule of thumb when in the US (If I ever go there again).... don't say you are unwell or you will be carted off, cannulated, O2 etc etc to find after hundreds or thousands of $$$$'s tests to find you have acute wind !!!! The problem with medicine in the US is you expect the best and most expert opinion rather than go to very fine and well trained primary care physician. Every chest pain is not an MI, every cough is not ca of the lung......Why waste money? Fossil

At Wed Apr 07, 08:23:00 AM, Anonymous Craig said...

You all are missing what actually happens in the FP/limited specialist referral issue. The patient shows up at the limited specialist without a referral so the chippy at that office calls the FP asking for the referral. The FP can refuse but that of course leads to one pissed off patient. You can live with one or two of those but, if it happens regularly, can you live with a panel of patients who are pissed at you and telling ten people they know? You will have to decide. It's coming.

At Wed Apr 07, 10:02:00 AM, Anonymous Anonymous said...

"Supply-and-demand will eventually work this out. There will be more need for primary care docs -- existing primary care docs will get more work -- more med students will find the primary care field appealing b/c it's more in demand.... It will probably take a few years to shake out, but I have confidence that it will, eventually, result in greater demand for, and utilization of, primary care docs."

But those conditions exist now, and no one wants to go into primary care.

Until the AMA's aggressively anti-primary care RUV schedule is eliminated or drastically reformed, there will be no primary care docs. Doing more work for less and less pay is not very attractive to most med school grads.

At Wed Apr 07, 04:28:00 PM, Anonymous Anonymous said...

@Anonymous Wed Apr 07, 02:18:00 AM, insured people show up in the ER because they're sick or injured and either don't have a primary care physician or are told that the next available appointment is months away. Strep throat and urinary tract infections aren't emergent conditions but they require treatment so if the ER is the only place you can be seen in less than a month, that's where you go.

Interesting twist to the silly notion that you can get universal coverage without a public option: Yesterday all but one (tiny)Massachusetts insurer stopped selling plans through the Commonwealth Connector because the state rejected their requests for rate hikes of 8-32%. (You read that right: 32 freakin' percent--in a state that already ranks as on of the most expensive in the nation.) So, anyone who needs to buy health individual or small-business health insurance now has 2 choices: Disobey the law and get fined, or buy a plan (that you're stuck with for a year) without knowing how much it will cost.

At Sun Apr 11, 08:16:00 PM, Anonymous mamadoc said...

I've been a family practice doc for almost 30 years now and I'll say it one more time:nobody wants to do primary care because the pay is relatively low (family practice, internal medicine and pediatrics take turns being the bottom of the feeding chain), the loans are high, and neither the insurance companies or the specialist respect the primary care doctors (especially the specialists,see above). And if you don't change that nobody ever will. So get used to seeing NPs now, because that is all that will be around in a few more years when all of us retire.


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