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When 32 Million New Patients Look For A Doctor

With the passage of healthcare reform, an estimated thirty two million new patients will try to find primary care doctors. That’s not going to be so easy because we already face a shortage of primary care doctors and about 13,000 more will be needed to take care of those newly eligible for insurance.
 
According to the American Medical Association, there are about 312,000 primary care doctors practicing in the United States. That includes family medicine, general practice (GP), internal medicine, and pediatrics. (In addition, there are 43,000 ob-gyn’s who also may serve as primary care doctors.) The estimate that another 13,000 will be needed comes from a study done by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care in partnership with the Agency for Healthcare Research and Quality.

 

Sixty five million Americans already live in areas that don’t have enough primary care doctors. And relief is not on the way anytime soon. It takes 5 to 8 years for a first year medical student to be trained as a primary care doctor. And the trend for budding doctors over the past decade has been away from primary care and towards more lucrative specialties.

 

The new legislation contains some incentives for entering into primary care. Medicare will pay a ten percent bonus to doctors spending most of their time giving primary care to the elderly. Medicaid payments will be increased by about 20 percent in 2013 and 2014 to reach 100 percent of the Medicare rate. This is important because about 16 million new patients will be eligible for Medicaid and many doctors currently don’t accept Medicaid because reimbursement is so low. In addition, primary care doctors will be paid extra for coordinating care among a team of doctors.

 

The new incentives are a good start but more is needed to increase our supply of primary care doctors. For this week’s CBS Doc Dot Com, my producer, Heather Tesoriero, and I traveled to a rural community in Indiana and discussed the shortage with an old-fashioned family practitioner named Dr. Jason Marker. When he started practice eight years ago he was $140,000 in debt from medical school loans. He works long hours and sees about 100 patients a week, but still owes $125,000. 

 

But Dr. Marker isn’t in it for the money and he’s not looking to heal only the well-healed. The day we visited him, a man walked five miles to his office from a homeless shelter. When I asked Dr. Marker what keeps him going after a rough day, he admitted that sometimes he wondered if it was all worth it. But then he added, “And then you go into the next room and you have a little old lady give you a big hug and you’re ready to go again.”

 

Click here to watch my interview with Dr. Marker.

 


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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