The secret to better health care

Tags: youens, health care reform, primary care, value

By Robert Youens, M.D.
TAFP President, 2008-2009

Hello, my colleagues. I have this bully pulpit for the next three quarters and intend to use it tastefully to express my opinion about the state of our affairs. So, here we go.

We are fortunate to be practicing the most fundamentally pure and satisfying medical specialty there is. Ours is a specialty of science and understanding, of the head and the heart, and of the definable episode and caring continuity.

Having practiced family medicine for the past 32 years, I know that part of what we do is to understand our patients in all their dimensions and create positive outcomes that are difficult to define but readily measurable. Multiple studies show better outcomes for less cost with primary care. I am also happy in the realization that family medicine is the pre-eminent specialty with regard to the application of science (evidence-based medicine). While it seems that others are having somewhat of a feeding frenzy to maximize income from interventions that are that are expensive and of questionable benefit (like vascular screenings and many others), family physicians simply continue to deliver the right care in the right place at the right time.

Since the turn of the 20th century and the publications of the Flexner report, medicine changed its training to a standardized curriculum based on scientific truth and academic rigor. As family physicians we have become the guardians of this discipline. Let us not forget it. We should never foreshorten our training or its intensity to satisfy demand for our specialty. Thus doing would demean our life’s work, lessen our value and suggest that others with lesser training are equally qualified.

Our health care system, as the Texas Primary Care Coali­tion says, is fractured. How did it get that way? In the middle of the 20th century, medicine was evolving with regard to the number of specialists and specialties, but there was an associated significant primary care base. It was easy for patients to discern the value of family physicians vis-à-vis their specialist colleagues, as the latter were more expensive and harder to find. They were special, after all. Family physicians and specialists had a value that was reflected in their cost and this naturally was evident to patients who perceived the difference. This was usually a cash-based system, and access to any care, not to mention specialty care, was limited by patients’ ability to pay. Due to this pay/access issue and taking the liberty of grossly oversimplifying the evolution of health insurance in this country, the federal government intervened in the 1960s with the establishment of Medicare and subsequently Medicaid.

Making a long story short, this occurrence, along with the demand that private insurers provide similar benefits, eliminated the value equation for family medicine. It was no longer possible for patients to see the difference in value between a family doctor and any specialist from a financial perspective. This led to an erosion of the doctor-patient relationship in favor of a perverse system that values technology over caring.

In an apparent paradox of intuition, those patients who had limited access to this technology and the specialists who utilized it were ultimately found to have better outcomes for less cost. The limiting factor was access to specialists and those with limited access did better. This time it was not so much financial access as it was physical access. And let me repeat, those patients who did not receive the “benefits” of ready access to specialist care did better. For less cost. DID BETTER FOR LESS COST.

The problem now, of course, is convincing people of the truth of this counter-intuitive outcome. As we gain traction with regard to this fact, the next and I daresay most significant problem is to restore the value equation for family physicians such that patients will perceive this value and behave accordingly. Though we have convinced some decision makers of the pre-eminent importance of primary care, even if we convince them all, what is to cause individual patients to use family doctors as their usual source of care? Money? Queuing? Gatekeeping? A massive and ongoing public relations/education effort? Beats the heck out of me. I think the horse may be out of the barn as far as limiting patients by financial means. Having to wait in line for specialty care is the worst of the single-payer system and not likely to be tolerated by Americans. Making patients see you for “permission” to see a specialist didn’t go over so big in the ’90s. And, education and advertising have not been tried.

Anyway, I’m happy to be a family physician and have every intention of maintaining my value through academic rigor, professional discipline and the continuous provision of understanding and compassion to each of my patients. I’m hopeful there will be a sea change in our health care system that will appropriately value our specialty. Until then I will continue to care for those enlightened patients who know the secret.

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