Fantasy? Meet reality …
One of the more persistent myths about the push for universal health care is its provision will solve our medical care problems and improve our overall health. Well there’s one problem with that – medical care depends on the availability of medical care providers, and we have a shortage of those. So while everyone may have insurance, insurance doesn’t guarantee access.
Massachusetts offers a snapshot of how giving more people insurance naturally drives demand. The Massachusetts Medical Society last fall reported just over half of internists and 40 percent of family and general practitioners weren’t accepting new patients, an increase in recent years as the state implemented nearly universal coverage.
The entire push of the new law is to shift the country from seeking care when they’re sick to seeking preventive care to help prevent sickness. That means a shift from primary care physicians who are essentially gate-keepers (to specialists) to primary care physicians as, well, the primary care source for the patient. One problem – primary care physicians only make up 30% of the physician population. Couple the shift in emphasis with the addition of 30 million newly insured and you can do the numbers yourself.
So how is this going to be reversed? Well here’s the plan:
Yet recently published reports predict a shortfall of roughly 40,000 primary care doctors over the next decade, a field losing out to the better pay, better hours and higher profile of many other specialties. Provisions in the new law aim to start reversing that tide, from bonus payments for certain physicians to expanded community health centers that will pick up some of the slack.
Or, in other words, government plans on incentivizing primary care with “bonuses” and essentially deincentivizing specialists. The obvious hope is some specialists will go back to school and become primary care physicians. But there’s a culture at work within the physician community which is going to resist that. The other hope is more will choose primary care in medical school. Again, that cultural hierarchy will, at least initially, resist that. The hoped for result is a flock of primary care physicians and far fewer specialists. Market forces? Ha! And ignore those doctors who aren’t taking any new patients or are dropping out of the insurance game altogether to charge annual fees for unlimited visits and consultation.
Anyway, the grand plan, once this shift begins taking place, is to take a team approach to your care in something you will lovingly call your “medical home”:
Instead of the traditional 10-minutes-with-the-doc-style office, a “medical home” would enhance access with a doctor-led team of nurses, physician assistants and disease educators working together; these teams could see more people while giving extra attention to those who need it most.
I don’t know about you, but that’s pretty much how my care works now. I see a PA. She refers me to my primary care physician only if there’s something out of the ordinary for which his expertise is needed. Otherwise it is the rest of the team that takes care of me. The only thing this law changes is the number of people out there seeking this sort of care as far as I can tell – and oh, yes – this system has been in place with my physician for years. So somehow I’m missing how what they’ve been doing for years has been inadequate, but now that government thinks it is a good idea and it will suddenly take care of all our problems concerning access, and improved care, etc.
Your “medical home” will also include the following. Now I’m a bit of a student of human nature – but this too seems to be a bit of a fantasy:
Rolling out next is a custom Web-based service named My Preventive Care that lets the practice’s patients link to their electronic medical record, answer some lifestyle and risk questions, and receive an individually tailored list of wellness steps to consider.
Say Don’s cholesterol test, scheduled after his yearly checkup, came back borderline high. That new lab result will show up, with discussion of diet, exercise and medication options to lower it in light of his other risk factors. He might try some on his own, or call up the doctor — who also gets an electronic copy — for a more in-depth discussion.
Tell me – if Don is concerned about such things and willing to search out and consider options to help his condition, don’t you reckon he might already be on WebMD or a similar site right now doing that? And if Don isn’t likely to do such a thing, is this “custom Web-based service” likely to entice him to log on and do so?
That’s the whole fallacy behind preventive care – it assumes that if it is offered it will be sought out and its recommendations followed – without exception. The assumption is that Don, who has never followed the advice of his doctor about his cholesterol will suddenly do so because we’ve shifted the emphasis of his care to prevention and provided him access to information.
And, with the shortage of doctors and increased demands on their time, how likely is Don to really get that “in-depth discussion” he wants from his doctor? Yeah, not very. So how likely is Don to get frustrated with all of this and revert to his old and more comfortable (albeit less healthy) lifestyle? Meanwhile, doc has lots of new patients admitted into the “home” that his “team” is trying to deal with preventively or, doc is simply not taking any new patients because he or she can’t spend the time necessary with those already in the practice.
The point? As with most things centrally planned, it sounds good on paper. But such plans tend to discount human nature. They also tend to be overly optimistic. And lastly, they usually underestimate or ignore the true numbers involved in favor of some fantasy result where everything works as planned despite those numbers. That’s what we see here.
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