Thursday, April 10, 2008

Universal Health Care and Primary Care Problems

So we’ve already established that patients like me are pretty much a primary care physician’s nightmare—complicated histories, hordes of specialists, all sorts of medications and symptoms to monitor. As I wrote a few months ago, though, some of those factors are the very reasons people like me need a good PCP, someone who can help coordinate the moving parts of disease management.

(As an aside, I have yet to find a group that is accepting new patients, but I’m going to renew my search now that a tough winter is over.)

Yet effective preventative medicine is the key to minimizing or even eliminating chronic disease, one of the most expensive and pervasive issues in health care. This is a given, and the logical extension of this is the idea that the more access people have to health care coverage, the better the outcome.

But theory and practice aren’t always as close together as we’d like. For example, here in Massachusetts a universal coverage plan was implemented several months ago. While costs have been significantly greater than previously estimated, a more compelling result is the one referred to in this New York Times article. In looking at the growing gap between urban and rural care, the article went on to posit this:

“Now in Massachusetts, in an unintended consequence of universal coverage, the imbalance is being exacerbated by the state’s new law requiring residents to have health insurance...Since last year, when the landmark law took effect, about 340,000 of Massachusetts’ estimated 600,000 uninsured have gained coverage. Many are now searching for doctors and scheduling appointments for long-deferred care.”

Of course, the fact that 340,000 patients are now covered is an encouraging one. But if one of the main goals of health insurance is to promote preventative medicine, how effective can it be if the patients who have lacked primary care medicine are unable to use their new insurance to see a physician? Or must wait months for an appointment?

Factors behind the primary care drought—lower salaries, educational debt, an aging population that demands more care—were already there. Add to that an influx of patients who all need the same resources, and it’s all too easy to see why doctors and patients alike are feeling the crunch:

“It is a fundamental truth — which we are learning the hard way in Massachusetts — that comprehensive health care reform cannot work without appropriate access to primary care physicians and providers,” Dr. Bruce Auerbach, the president-elect of the Massachusetts Medical Society, told Congress in February.”


Aviva said...

Wow, great post, Laurie!

I strongly favor universal health care and the kind of legislation that was passed in Massachusetts, but like a lot of people, I hadn't thought of the implications of physician shortages. So many parts of the country already struggle with not enough doctors to serve the population ...

And as you mention, one of the big problems is how difficult it is to get a good primary care doc. I feel very fortunate to have the one I found serendipitously, but in the past I've struggled to find a PCP who both accepted new patients AND was someone I liked and could work with.

And I don't know what the answer is to the shortage of PCPs. Health care costs have risen so high it's hard to suggest we pay doctors even more. But the truth is that internists and other PCPs really don't earn that much money when you look at the level of education they've achieved and the kind of debt almost all of them had to take on to get that MD. And the kind of hours they work is crazy -- they're jam-packed with back-to-back patients and then after a 10 hour day or more, they go home with armloads of paperwork to do.

It's not a job I'd want, and it's not a job I'd wish for my daughter. (I must be the only Jewish mother on earth who doesn't want her child to grow up to be a doctor nor to marry one! :)

Rick Frea said...

Great post. And a perfect example of why the people should be wary of the gov. getting involved in healthcare.

Anney E.J. Ryan said...

For me, I see Mass Health Care as forcing people to have health insurance. I still can't afford it. No one's come after me yet, but I know they will. Then I will have to find some way to manage. My opinion is really not educated on the topic. However, I think that health care needs to be made affordable, before it can be forced on all.

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Anonymous said...

Patients like you are not a good primary care doctor's nightmare, but a dream! We went into primary care because we love complexities, we love treating the whole patient, and we enjoy close relationships with patients that are so important for successfully managing chronic diseases.
The problem is the system, which reimburses for procedures and tests substantially more than it does time spent with patients discussing the management of their chronic illness.
People, including doctors, usually behave logically when it comes to renumeration. If doing procedures and ordering tests increases reimbursement, and spending time talking to patients does not; the reason why it is so hard to find a primary care physician is pretty obvious.
We don't necessarily need to pay every physician more money, but rather reallign incentives so that preventing illness and managing chronic disease (rather than diagnosing and treating complications) is valued.

Moses Gunner said...

Did you see the Bunk study stating 2/3 of doctors in America want National Health Care. The doctors who did this study also conducted one in 2002 and found that the majority of doctors did not want national health care, the problem with this is that the 2 question surveys drastically differ in there 2nd question. I found this article, 60% of Physicians Surveyed Oppose Switching to a National Health Care Plan, It's worth a read

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