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Why We Need Private-Practice Primary Care Doctors

A recent post on Kevin MD by Joseph Biundo, a rheumatologist, challenged my assertion that primary care doctors can save money:

(In reference to my claim…) That may be true in theory, but I see patients in my rheumatology office every day who have been “worked up” by primary care physicians and come in with piles of lab tests and X-ray and MRI reports, but are diagnosed in my office by a simple history and physical exam.

Prior to that, an article in the New York Times along with a post by Kevin Pho noted the fact that more solo practitioners are leaving private practice and joining hospital systems. Why are they doing this?

Dr. Kevin suggests the following:

Lifestyle matters. More doctors are entering the workforce seeking part-time jobs in order to maintain a family balance. By removing the administrative hassles from their plate, they can go back to focusing solely on practicing medicine and coming home at a reasonable hour.

The NY Times article suggests possible benefits to patients:

In many ways, patients benefit from higher quality and better coordinated care, as doctors from various fields join a single organization. In such systems, patient records can pass seamlessly from doctor to specialist to hospital, helping avoid the kind of dangerous slip-ups that cost the lives of an estimated 100,000 people in this country each year.

So as a primary care doctor in private practice, am I soon to go the way of the dinosaur? Is this simply a shift in the business model as demanded by the times, or should people be concerned?  Would the system function better with fewer primary care doctors or ones who are employed by large hospital systems?

Those who read my blog regularly already know my answer:

Private primary care is essential for a healthy healthcare system.

Why Primary Care?

While I can’t disagree with Dr. Biundo on his point regarding the physical exam skills of primary care physicians (PCPs), I do disagree that this raises question of the cost-effectiveness of primary care. In his case (the practice of rheumatology), there are few expensive procedures, the diseases are less common (compared to fields like cardiology and other high cost specialties), and the patients don’t spend a high number of days in the hospital. One overnight stay for a cardiac catheterization will pay a large part of a rheumatologist’s salary for a year.

Like primary care, rheumatology is largely an outpatient practice, with success being measured by the ability of the practitioner to keep the patient out of the hospital and away from expensive procedures. Lately, rheumatologists have started having biologic medications (like Enbrel) that are quite costly, but the number of people on this relative to the general public is still quite small.

Primary care, on the other hand, is the fountainhead of all healthcare costs. A good PCP is also measured by patients staying out of the hospital and away from expensive procedures. In general, a PCP is less likely to:

  • Order an x-ray compared to an orthopedist,
  • Get an EKG compared to a cardiologist, or
  • Order an endoscopy compared to a gastroenterologist.

There are some high-consuming primary care doctors, but much of the blame for this can be placed on the payment system that encourages expensive procedures and the ordering of tests. For example, one of the PCP groups in our area has their own stress-testing equipment and CT scanner. I am 100% sure that the physicians in this group order many more CT scans and stress tests when compared the physicians in my practice. I am also sure that the care quality in my practice does not suffer from our lack of test-ordering.

Why? Because the physicians are financially motivated to order these tests, making the appropriate business decision clash with the appropriate medical decision. As long as it’s not harmful to order the test, the doctor can justify it.

Even these physicians, however, are not going to do any of these tests as much as a specialist, who depends on the presence of chronic disease to make a living. The only specialists I have seen who are slow to order tests and procedures are those who don’t financially profit from their ordering: academic specialists.

Why Private Practice?

This brings me to my second point, which is the necessity of having primary care physicians who are in private practice.

Why do hospitals have an interest in hiring primary care physicians? The answer is twofold: first, they allow them to negotiate contracts with the insurance companies in a position of strength. Primary care is a must for most insurance contracts. Patients will change insurance plans if their PCP is not on the plan, but they won’t do so nearly as much for specialists (with the possible exception of OB/GYN, which often act as PCP’s) or hospitals. Plus, most insurance plans do their care management by requiring referrals, denying or accepting them being their means of cost control. Primary care physicians are the referring physicians, and without them the hospital’s negotiating power is greatly diminished.

The second reason hospitals want PCP’s under their wing is that they generate business by ordering radiology tests, lab tests, and sending patients to specialists who will do expensive procedures in their facilities. Primary care is a loss-leader to hospitals. Hospitals make no money off of their PCP practices directly but make a huge amount from the referrals and procedures they generate.

This shifts the mission of the PCP. The “success” of the PCP in the eye of the hospital system is not to avoid referrals or costly procedures, but to order them. It’s not bad in the eye of the hospital that the PCP has higher hospitalization rates, it’s better.

The Answer

The solution from an overall cost standpoint is to give primary care physicians incentive to do what they should be doing in the first place: keep people healthy and away from hospitals. Any system that places too much value on procedures is going to fail at this, as the institutions and individuals who profit off of the procedures are going to fight for control of PCP’s. Independent PCP’s who profit from keeping people well are the best thing for a system.

I have lived in both worlds: as a private PCP and as a salaried physician from a hospital. I left the latter because it was clear that they had no interest at running my practice well and really just wanted me to be a turnstile into their money-making procedures. It would be a big mistake to take away the one specialty that restrains cost. We need to do the opposite and encourage good primary care medicine.

*This blog post was originally published at Musings of a Distractible Mind*


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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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