Another Reason For Doctors To Avoid Primary Care Medicine

Posted on October 8, 2007
Filed Under Gekkonian Rationing, Primary Care in America |

As everyone knows, young doctors are avoiding primary care medicine in droves. And while healthcare policy experts feign great puzzlement as to why this might be, the answers seem pretty obvious. The pay (which is not determined by the market, but by Acts of Congress) is low, the hours long, the prestige diminishing. Primary care docs are on the front lines of covert rationing, their time-spent-per-patient-visit being carefully limited, and the content of those visits increasingly scripted by central authorities. Furthermore, the diminishing repertoire of services they can offer (what with more and more medical disorders being placed in the province of “specialists”), increasingly overlaps with the growing repertoire of nurse practitioners. Reasons for frustration in the practice of primary care abound.

Now, on top of all that, comes yet another reason the practice of primary care medicine may become even more frustrating. According the the Wall Street Journal yesterday, employers are trying to save money by hiring “care-management consultants”, who will contact their employees directly about “alternative” treatment options for their medical conditions.

The WSJ describes the process thustly:

Care managers often use data-mining computer technology to examine insurance claims and target for special help employees with serious and costly conditions such as cancer, neonatal complications and severe injuries. They also review physician treatment plans for compliance with the best practices established by government agencies and medical groups. They often strive to improve care for patients, and save money for employers and insurers, by recommending less invasive and less expensive procedures and drugs.

To the extent that the patient’s doctor is a suboptimal practitioner, of course, then such a process might be helpful to the patient’s outcome. But to the extent that the doctor has already considered the data, the guidelines, and the patient’s special circumstances, and has, with the patient, arrived at an individualized treatment plan that best suits that patient’s own needs, then a phone call from a “care manager” that calls that treatment plan - and the doctor’s competence - into question might harm the patient’s outcome. Either way, this process threatens to undermine the patient’s confidence in his/her doctor, and it certainly blows apart whatever might remain of the sanctity of the doctor-patient relationship.

Since the care management outfits are paid by the employer or the insurer (and not the patient), then its chief goal, obviously, is not to improve patient outcomes by making sure that doctors adhere to approved guidelines in all cases, but instead to reduce costs by making sure that doctors adhere to those guidelines that will result in less spending. Guidelines that will result in more spending will be ignored.

(DrRich will take this all back and issue a public apology when he hears of a care management company that makes a general practice of calling patients with cardiac ejection fractions of less than 35% and telling them, “You know, the guidelines suggest you ought to consider an implantable defibrillator. We don’t know why your doctor failed to bring this up. But we’ll be happy to make the referral to an electrophysiologist, and your insurer will be delighted to kick in the $40,000 so you can get this done, thus greatly improving your odds of a favorable outcome.” )

In any case, for young doctors who want to enter a profession that gives them personal satisfaction, a sense of professional pride, and a degree of professional autonomy commensurate with their education and experience, it is more and more difficult to imagine primary care medicine meeting those needs.

Policy experts who shed crocodile tears over the falling numbers of primary care doctors are getting precisely what their system is designed to give them: primary care medicine dictated by centralized committees of “guideline”-producing experts, and administered locally by a new kind of practitioner (not necessarily, and preferably not, a physician) who is more likely malleable, less likely a prima donna, and not at all mired in quaint historical notions of professional autonomy.

Comments

7 Responses to “Another Reason For Doctors To Avoid Primary Care Medicine”

  1. Dan on October 8th, 2007 1:54 pm

    This is another case where Gekkonian and Wonkonian tendencies are virtually indistinguishable. I can hear the siren song of the Wonkonian managers lulling me to sleep by promising that this will indeed provide best care to the “members” (note that “patients” have ceased to exist in the Wonkonian world, as have “physicians”: we are “providers” now.

  2. Martin on October 10th, 2007 3:07 am

    Can we think of these people as anti-pharma reps? Has big pharma done too much so we need to fight back this way?
    M.

  3. Ddx:dx on October 12th, 2007 12:47 pm

    As a family physician I want to clearly express my ambivalence. Yes, sometimes I think I can manage the patient best and wish SOMEONE would pay me a reasonable wage to do this. But there is a problem and I see it commonly. We, as primary care doctors are in the business of caring for patients and an unhappy, angry patient is bad business. I see lots of doctors doing bad medicine just to avoid a confrontation with a pushy patient. In the online magazine”HEALTH” a week ago there was an article about how to lie tp or lean on your doctor to get him to order the tests you want or think you need….The MRI for vague knee pain, you know the list….So, if there is no gold standard, no protocols, do we trust each doc to ‘do his best?’ What is the doc’s motivation? You come down clearly on the Motivation for the care management consultants, but we all have motivations in our lives. And docs are people too.
    So we trust docs to do what’s best for the patient…..That’s what we’re left with at this point. One of the main reasons I quit the group I was in was the lack of discussion about quality, the resistance to an effort to establish quality measures…Difficult, threatening, and ?worthwhile? My partners would rather be seeing patients…Running harder to stay in the same place. So, I quit after 17 years of office family medicine and read blogs on ER shifts….

  4. Dawn on October 12th, 2007 1:05 pm

    DrRich…I have to disagree with you in some ways. I have many friends who are care/case managers, nurses, many with advanced degrees (mostly organ transplant and pediatrics. Can’t speak for the cardiac members).

    If you ask them, their job is to obtain the best care that fits the patient’s needs. I have heard about the case managers arguing with the claims department, getting denied claims paid because, even if the service is not generally necessary, it is for THIS patient. They win more than they lose, but they do lose. Yes, their goal is also to save money for the company they work for. But they are also saving money for the other members who have insurance, so premiums don’t skyrocket every year.

    No, they won’t help the paraplegic buy a hand-controlled van. But they will help get the liftgate needed to get them in/out of the van installed and paid for. No, they won’t help you pay for remodeling your house but yes, they will help you get the equipment needed to care for the person in the house that is medically necessary.

    Yes, they will help you get your organ transplant approved, and guide you on all the insurance steps needed. But they won’t arrange to pay for it if the person isn’t eligible (medically or otherwise). They rarely question a doctor’s treatment, as long as it is EBM based. They won’t help you get the insurance to pay for the chelation for athroscleosis, the homeopathic medications, or other non-proven treatments.

    I apologize this is such a long rant. But you pressed one of my buttons! I like your writing, though, and I’ll be back to read more.

  5. DrRich on October 12th, 2007 1:35 pm

    Ddx:dx,

    I’m not trying to say here that doctors always do the right thing medically, or that they even always try. I, too, have seen a lot of docs do a lot of boneheaded things. The system today makes it hard not to, and doctors, like other humans, tend to respond in human ways to stress and loss of control. I’m merely saying that this new practice by employers and insurers passes the following message to PCPs: “We’re going to assume you’ve not made the best decision for your individual patient. But we’re not even going to talk to you about it, we’re going directly to your patient.” Whether doctors deserve this or not (and admittedly, more than a few do), this practice will further enervate them, and it provides just one more reason for young doctors to avoid primary care medicine altogether.

  6. DrRich on October 12th, 2007 1:45 pm

    Dawn,

    I too know several excellent nurses who have become case managers, and I can truthfully say that these individuals probably worry a lot more about what’s best for the patient than do many doctors I know (just as you suggest). My post was not meant to denigrate case managers. I know from experience that in most cases what you say about them is true. My post instead was meant simply to suggest that the apparently growing practice of insurance companies and employers to routinely use case managers (as excellent as they may be) to second guess the actions of doctors (as illogical as those doctors may be), then call those second guesses directly to the attention of patients (as deserving as those patients may be), is just one more reason for young physicians to seek to avoid primary care medicine. That’s just human nature.

  7. The Covert Rationing Blog » Blog Archive » Why Implantable Defibrillators Have To Be Rationed on November 7th, 2007 9:39 am

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