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Health reform is more than just insurance

A story on the Internet describes how a senior IBM executive went straight to a cardiologist to treat his chest pain. Several serious complications and $200,000 later, the cardiologist cleared him of any heart problems. The patient then saw a gastroenterologist, who performed yet another big workup without finding a gastrointestinal cause. Finally he saw a primary physician, who discovered the pain was due to muscle spasm in the chest.

Much of the debate about health reform focuses on covering the uninsured and reassuring the insured they won't be cut off. But just providing insurance won't fix medical care or improve the health of Americans. And the cost will continue to escalate without limit. Our healthcare system itself is broken. It's been hijacked by "experts": policy wonks and business types who have no idea how to actually care for patients.

I've practiced internal medicine for many years in a variety of settings. If possible, I'll never again work for managed care. I'm no longer willing to rush through patient visits, spending half my time apologizing for all the corners we have to cut. Now I see only those willing to pay the modest extra cost for "out of network" care. I have no managed care contracts, which allows me to spend the time I believe my patients need for proper care. My income is less, but I sleep well at night because I deliver the best care I know how.

Most of the people commenting about health care fundamentally misunderstand the practice of medicine:

1. Medicine is extremely intellectually challenging and difficult to do well. It's easy to slide through a patient visit and treat only what's obvious, but this yields incorrect diagnoses and treatments a substantial minority of the time. Most MBA and economist types view physicians as commodities -- replaceable parts. If you obtain your personal care in this manner, you deserve the poor outcomes you will receive. (Similarly, if you blindly pick your attorney out of the phone book, you will lose your case.)

2. Quality care and good outcomes require spending enough time with the patient to perform a thorough history and physical examination. If one listens carefully to the patient, often the problem is obvious. Mostly one does tests as a form of due diligence: to confirm the diagnosis and to rule out unlikely alternatives that must be considered, like anemia, thyroid disease, cancer, etc. It's simply not possible to perform an adequate office visit in seven minutes for more than the simplest problem. I often spend an hour or more doing a comprehensive history and physical exam, and there's not a minute of fluff or wasted time.

3. I've seen lots of medical records over many years of practice. What makes the Mayo Clinic and similar top-quality care so special is that those physicians obtain an extraordinarily detailed history and perform a thorough physical examination. When you read a Mayo history and physical, you learn exactly what's going on with that patient. The reason treatment at the Mayo Clinic costs less than comparable care in the community is they emphasize time with the physician, not performing procedures.

4. Occasionally patients are harmed or killed by perfunctory care, but usually the result is spinning one's wheels. Many doctors compensate for inadequate assessments by ordering a bazillion tests; then they treat the test results. But unthoughtful tests are notoriously unreliable and lead to wild goose chases, wasted time, huge bills, and poor outcomes. For example, it's common for rushed or unskilled physicians to order an MRI scan to evaluate low back pain. But a majority of perfectly healthy people over age 35 have abnormal low back MRIs, and most people with back pain have soft tissue problems you can't see on a scan. Blindly treating the MRI is a great way to increase the cost of care and harm the patient. (On the other hand, when the clinical picture warrants an MRI, it's important to do.)

5. Specialists and physicians specializing in performing procedures form the backbone of treating certain conditions in the same way that the car repair business requires shops that specialize in overhauling engines or transmissions. But only an idiot would take their car to a transmission shop for a vague engine problem. Patients love the glitz of high technology but don't realize it's a tool that's only as valuable as the thought going into its use. One great example: total-body CT scans to screen for illness turn up dozens of red herrings -- subtle abnormalities that almost always mean nothing but require follow-up -- at the cost of a massive radiation dose.

6. By now it should be obvious why the scientific data clearly show that in areas like Miami where most care is provided by specialists and proceduralists, the cost of care is 30% higher, and outcomes are demonstrably poorer. In contrast, in Minnesota and other parts of the country where primary physicians dominate, the cost is substantially lower and quality much higher, however one wishes to measure quality. "Specialist-first" care is a prescription for high cost and poor outcomes.

7. But the unique propensity of the American system to pay for doing things to patients -- rather than properly thinking through the diagnosis and treatment -- means that to practice primary care is to constantly wrestle with insolvency. Thus only a tiny minority of medical students are entering primary care specialties, and the whole healthcare system is at risk. (See "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care," from the American College of Physicians.)

8. Using mid-level practitioners has been touted as a panacea to lower costs, but it won't work. I've practiced in several systems with nurse practitioners and greatly value their contribution. Nurse practitioners and physicians assistants are terrific adjuncts in providing treatment, but they don't save money. The NPs I've worked with take twice as long as a skilled physician to treat a patient and are paid half as much. They work best treating simpler cases or, in a large system like Kaiser, specializing in one problem, e.g., treating low back pain or providing birth control. Bluntly stated, few NPs have the training, experience, or intellectual resources of a competent physician and are out of their league in complex cases. (Would you want to be represented in court by a paralegal?)

What's the solution? We need to find a way to make primary care affordable for patients -- and to pay primary care physicians enough so they can afford to be in that specialty.


Last updated Fri, Jun 19, 2015

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©2011, James Gagné, MD