The author of this article falls victim to the type of fault that he seeks to illustrate. He spends paragraph after paragraph telling us about what he percieves as the problem, while devoting precious little time to discussing the solution. Even in the comments that I have read on this article so far, few have focused on how to fix the problems that they so passionately rant about.

Let's change the focus here.

I am the practice manager for a private Family Practice clinic in a rural area. As such, I deal intimately with both the clinical and economic realities of the practice of medicine in our country on a daily basis. As far as I'm concerned, both the diagnostic focus maligned in the article, and the treatment-oriented apporach advocated by the author, miss the point that lies at the root of the failings of our current apporach to medicine: Both of these appraches address treating disease after it has already occurred.

The horses are already out of the barn. Elvis has already left the building.

The only way we can truly begin to address the healthcare crisis that is emerging in this nation is to recognize not only the value, but the absolute necessity of preventive medical care.

Many of the conditions that physicians rush to daignose and treat in shrinking windows of time with diminishing reimbursement are preventable. Even with existing conditions where disease is already diagnosed, efforts can be made to reduce the damage caused to physiological systems by the disease state. All elements of our healthcare system, from insurers to providers, must begin to realize that early control of conditions, even and espeially before they become symptomatic, will save us all billions of dollars in overall healthcare costs in the long run. If insurers, in particular, were to act on this fact, we might really begin to create a healthcare system that serves both our citizens and our economy.

Reimbursement for medical tests and treatments is based on an outmoded, diagnosis dependant model. Insurances reimburse screening for most conditions only in the presence of clinical symptoms or demographic factors which indicate that the presence of disease is more likely. We are thus prevented from screening to prevent disease, but forced instead to confirm disease that we suspect may already exist. Insurances will only authroize payment for medications to treat disease states that are already advanced to the point of being symptomatic. The damage is already being done, and we can only reduce the amount of harm, and the rate at which it occurs. This reactive posture must change for meaningful reform and cost management to occur.

One of the keys to all of this lies in the recognition and adequate compensation of primary care practitioners. These practitioners on the "front line" of medical care are ideally placed to provide the kind of proactive care that is so deperately needed. Embedded in their communities, and armed with adequate time to build comprehensive family histories and provide thorough patient education, these providers can and would revolutionize the state of healthcare in this nation.

The key factor above is time. As we all know, time is money. The problem lies in the fact that primary care remains the most inadequately compensated segment of our healthcare system. In response to shrinking reimbursement, primary care providers are forced to see an increased number of patients each day to compensate for lost revenue. The result is that less time is being spent with each patient, which leaves the provider with little time in which to get histories and provide the education that is so desperately needed to provide a new, solid foundation to our healthcare system. Furthermore, the poor salary that is earned by these most desperately needed providers attracts fewer and fewer of the best and brightest minds that come out of our medical educational system. The most promising graduates move into specialty training that often focuses on the care of those who are already desperately ill.

Can you see the problem here?

We should reward the prevention of disease, not the treatment of it. We should not react to a diagnosis, but prevent it from ever being necessary. The cost savings that would be realized by a proactive approach to healthcare would allow for greater compensation of the primary care providers who could make it happen, which would in turn attract more of our finest to those arenas of care. This would then allow us to become even more effective at preventing disease. With greater research into the genetic and environmental underpinnings of disease and preventive treatments based on that research, we could truly move into the kind of medical future that we all should be working toward.

Wow, nice post.

This should get a check mark. More emphasis on prevention with better education wouldn't fix all our health care ills but it is the first place we should start. I also agree with your position of how we should reimburse primary care physicians.

There will have to be an expansion of our vocabulary and much more efficient means of accessing the following kind of concepts if prevention is going to be really cost-effective:

Risk = Probability of a bad outcome

Risk Factor = a factor that if present increases the probability of a bad outcome

Protection = Probability that the bad outcome will not occur

Protective Factor = a factor that if present decreases the probability of a bad outcome

Resistance = Probability that a disease process will progress once it has started

Resistance Factor = a factor that if present decreases the probability that a disease process will progress

Resilience = Probability that a disease process will lessen or regress toward a more normal state

Resilience Factor = a factor that if present increases the probability that a disease process will regress

All of the above factors and concepts can be important for an understanding of how to "practice prevention".

Systematically scan and review literature on:

Risk; Risk Factors

Protection; Protection Factors

Resistance; Resistance Factors

Resilience; Resilience Factors

Identify key components of each of the above for patient prevention

Place summaries, patient handouts in a free "text expander program" - FlashText

On FlashText create the following (and many more to assist with diagnosis using pertinent review of systems lists for example) tabs to handle the large amount of information:

Protection; Protection Factors; Resilience; Resilience Factors; Resistance; Resistance Factors; Risk; Risk Factors

When one sees a patient and recognizes the need for information in each category (or seeking that information) look down the columns under each tab for pertinent information at the point of care that can be loaded into the note at a push of a button.

Have a process to assess the effectiveness of this approach in a busy practice.

Correction:

Should have defined Resistance as:

Resistance = (1 – Probability) that a disease process will progress once it has started

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I was thinking along the exact same lines as I read through the article, then found that you had beaten me to it. Taken alone, giving preventive care its proper emphasis and reimbursement is probably not enough to save our healthcare system, but it would be a marvelous first step. Plus, it would pay me better. Hooray, me!

Just kidding about that last part; I'm under no illusion that pediatricians will ever be paid equally with our peers. But an excellent post regardless - you summed up my own thoughts with more elegance than I could likely muster.

As an academic subspecialist physician who cares for both adult and pediatric patients, my first thought when I read your post was: yeah, right...

I only see adult patients when I absolutely have to, mainly because they can always be relied upon, in the absence of some catastrophic event of sufficient pain and/or economic impact, to do exactly what they want to do. If they feel relatively "well" and are able to still do the things they have to (i.e., still earn a living) and want to (i.e., golf, play with their kids/grandkids), they can be relied on to continue smoking, eating Twinkies, and watching hours upon hours of television every week. You want prevention? By all means, I agree that it would be a better thing than to treat catastrophic conditions. But don't tell physicians that they should be reimbursed based on their ability to prevent an outcome that is almost exclusively outside of their control. Instead, a far more powerful motivation will be to CHARGE PATIENTS who do not comply with recommended lifestyle changes.

And as one other poster pointed out, Pediatricians care for patients who almost exclusively do NOTHING to bring their conditions on themselves. And Pediatricians got on the prevention and guidance bandwagon long before the adult medicine folks did. But they still get reimbursed for bupkus...

I absolutely agree. The main article does not touch upon an invaluable portion of healthcare, perhaps the most important aspect of health care: Prevention. In our healthcare society (which differs from the more common socialized healthcare) prevention is not rewarded, but fixing the problem is. The issue lies in how we think as Americans and indeed as human beings: Most patients never thank their family practitioner (FP) or public health nurse for educating them on the harmful effects of smoking. Instead, smokers enthusiastically thank their cardiothoracic surgeons for "saving their life" or "giving them a new start." Glory then lies with the hero who fixed a failing heart and the FPs are left for attack for "not encouraging enough prevention" in spite of all their efforts.

CJM3:

You want prevention? By all means, I agree that it would be a better thing than to treat catastrophic conditions. But don't tell physicians that they should be reimbursed based on their ability to prevent an outcome that is almost exclusively outside of their control. Instead, a far more powerful motivation will be to CHARGE PATIENTS who do not comply with recommended lifestyle changes.

It is quite true that physicians are unable to control patient adherence to lifestyle modifications and other treatment recommendations. However, reimbursement could just as easily be tied to preventive effort. By documenting advice for controlling cholesterol levels and hypertension, for example, as well as agressively screening for those and similar known risk factors and controlling them early, the odds of preventing progression of disease can be increased. Not all of those efforts will be successful in terms of the end goal of prevention of disease, but as the Great One once said, "You miss 100% of the shots you don't take." If we reach even one in ten at-risk patients on these risk factors alone, we can go a long way to reducing the rate of adverse outcome from cardiovascular disease. Just imagine reducing the incidence of MI by 10%. The cost savings to the healthcare system would be enormous.

I'm not suggesting sweeping changes to the way that medicine is practiced (not yet, anyway... baby steps first). Begin by reimbursing more generously for existing screening measures (and easing the reimbursement threshold for those measures). Elevate reimbursement for E&M codes 99213 through 99215, as these core primary care codes generally involve servicing diagnoses that could respond to aggressive preventive measures (in our practice, at least). Tie that increase to preventive focus, if you wish, or expand allowable circumstances for using the -25 modifier to include preventive counseling and screeningas a distinct billable service. Mandate universal full coverage for an annual preventive care visit for all patients. Small measures such as these could begin to change the momentum, and would begin to make prevention an economically viable way to practice medicine.

The problem remains that insureres do not calculate risk on a long enough time scale. Most patients will be insured with numerous companies over their lifetimes. One study (abstract can be found here: <link>) found that 50% of patients changed insurers within 2 years, with fewer than 15% staying longer than 8 years with a single insurer. This turnover leaves insurance companies with no financial incentive to be concerned about prevention. When faced with a model of reimbursement that provides the greatest long-term benefit, they see only a potential increase in their near-term costs. Unfortunately, this short-horizon model for maximizing profit by minimizing cost results in greater costs for the system as a whole.

This, too, must change if we are to effect any meaningful reform of our healthcare system.

A way to make this more cost-effective for insurers would be to do as you suggested, and charge patients for non-adherence. Patients who fail to see their doctor on a regular basis in order to avail themselves of such preventive services, once they are actively encouraged and reimbursed, should be charged higher premiums. This would pass the greater costs to the system incurred by their failure to address risk-reduction on to the person most directly responsible.

Of course, this would promote a model of personal responsibility that is rather out-of-fashion in our society. However, that model also represents a much-needed paradigm change in our national attitude toward healthcare. By promoting personal responsibility and active involvement of the patient, and making them realize the importance of their actions in the care of their health, we can make them realize that they are the true stakeholders in the rising cost of healthcare in this country.

Prevention and early diagnosis are the holy grails of medicine and a much more effective strategy than treatment alone.

Our health care non-system's problem, however, is the lack of value. We are inefficient and costly. People cannot afford to enter the system. Part of this is the 30% for administrative costs of the 2 trillion spent on health care. Another factor is our generation long system of patents which allow predatory pricing not based on actual costs of the product but on a "your money or your life" philosophy.

There are many other issues, but suffice it to say that we need to demonetarize medicine and make patient outcomes and efficiency our goals, not profits. Free markets, for what it's worth, as in our banking system just don't work and we need to move on to another approach.

www.medicynic.com

The comments in this thread balance the article by pointing out the financial pressures and time limitations that many physicians function under and showing how this can lead to less than optimal outcomes for patients. However, as others have pointed out, there are additional health professionals, like nurses and health educators, who could stand in the gap and provide necessary information and education to patients-if this was a priority.

I view the more pressing issue to be that the healthcare system-as a whole-focuses more attention, more energy and spends more money on treatment of diseases rather than prevention. Studies show that the United States healthcare system routinely spends up to twice the amount of resources on treating the effects of chronic conditions (like heart disease and diabetes) than it does on preventing them.

There are many factors that play into this, but the irony is that disease prevention is usually more cost-effective from a medical standpoint than treatment. Unless there is an attitude shift that leads to more funding and support for disease prevention and health education programs, we’ll continue to see primary care physicians-who could be actively engaging and teaching their patients healthy lifestyle choices- instead acting as the first line of defense.

Bridget Chapital, CHES