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If I Could Fix One Thing About U.S. Healthcare…

In my post yesterday about lessons we can learn from Israel’s health care system I wrote:

So, yes, the focus on health insurance reform will lead to many changes, and more complexity.  And some day, years from now, someone will be explaining the American system to an audience, and people will wonder, how did anyone ever create a system such as this?

In response, a friend of mine challenged me:  if the system is too complicated, how should we simplify it?

I wish more policy-makers were asking this question.

For me, the answer is clear: Primary care.  Time was, your primary care doctor was able to serve as the hub of your medical activity.  He or she could spend all the time needed to figure out what was wrong and to coordinate with your specialists.  It’s not true anymore.  Patients are left on their own trying to navigate the system.  In many ways they end up acting  almost as their own primary care doctors.  Patients try to pick their specialists, find out what to do about their condition, decide on good treatment choices.

It’s a problem that is well reflected in data collected by Best Doctors from people calling for help with that process.  Here’s our latest data on why people call:

Primary Reason for Call

Need help deciding among treatments          46%

Symptoms not improving                                   27%

Don’t understand diagnosis                              20%

Skeptical of doctor                                                 8%

It tells quite a striking story.  Patients, on their own, end up struggling with some very fundamental questions.  You could say that their primary care doctors should resolve these questions.  But with typical primary care doctors carrying as many as 5,000 patients and spending 15 minutes or less in each visit, it shouldn’t be surprising that they can’t.

What’s worse is what happens in this environment.  Studies – and Best Doctors data – show that 15% or more of patients end up with the wrong diagnosis, and more than half end up making the wrong treatment decisions.  The biggest reason?  The cognitive errors that happen when you try to make complicated decisions with fragmented information and insufficient time.   We estimate that, on average, each time you fix one of these problems you save about $20,000.  But sometimes it’s much, much more than that – and I’m talking about more than just money.

You don’t have to believe me, though.  An increasingly significant body of research shows that focusing resources on primary care is the best way to address the fundamental cost and quality problems we face in health care.  Reformers still aren’t getting it.  Pay more money for primary care?  The conventional wisdom says that doctors who say this are just trying to make more money for less work.  Really?  If a primary care doctor spends more time with his patients, he can do a better job figuring out the patient’s diagnosis, guiding them to the right treatment choices, and helping them, as a human being, cope with the difficulties of being sick.

So, if I had to pick just one thing to fix in our health care system, it would be this.  Focus on making primary care the fundamental basis for the system.  I think it is clear that it would save substantial amounts of money and lead to higher quality medical care.  But it would do more than this.  As Dr. Robert Centor said recently:

Patients need physicians who spend time with them. Patients need physicians who sit down, look them in the eye and talk. Patients need honesty and empathy.

He’s right.  Any health care system, or health care reform, that doesn’t create a stronger doctor-patient relationship, is failing.

*This blog post was originally published at See First Blog*

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2 Responses to “If I Could Fix One Thing About U.S. Healthcare…”

  1. Alain Ochoa says:

    What’s striking is that many times doctors are not really asking for more money but for more primare care physicians so each of them can spend more time with their patients. So yes, strengthening primary care means more money, but a better investment. All countries seem to fail on this point, though.

  2. Evan Falchuk says:

    So true, Alain. There is a systematic devaluing of primary care, and a total failure to understand the consequences of doing that. We need more voices to speak the truth about this problem.

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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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