Reacting to the Future of Primary Care

There is a provocative Perspective article in the November 13, 2008 issue of the New England Journal of Medicine. The basic question argued about is whether or not it is physically possible to provide primary care to the extent required to prevent illness and treat chronic disease effectively. There are so many things a primary care provider must do that she or he would need to work 18 hours every day. Whereas a specialist can focus on just one part of the body or one illness, a primary care provider must focus on everything from acute illness to preventive care to managing chronic illness -- and all in a 15-20 min patient visit. What do you think? No time to read the article? Check out the video.



As an example from my own practice, a 72 year old man has just been discharged from the hospital after being admitted for shortness of breath. He has chronic illness which include the following: diabetes, hypertension, coronary artery disease, sleep apnea, renal failure, severe arthritis, glaucoma and high cholesterol. He needs his list of medications from the hospital reconciled which what he was taking before he was admitted. In addition, he is due for his flu shot and other preventive interventions. Go. You have 20 minutes start to finish.

And, don't forget the follow up phone calls to pharmacy and specialists after the visit is over. Of course, now we have email too.

Is this an extreme example? Not really. Many adult patients suffering from chronic illness have more than one; way more than one.

As of 2008, health care providers get reimbursed based on the individual patient encounter. One visit equals one payment. Complexity of illness only plays a minor role in the amount of reimbursement, and all work done outside the exam room doesn't count. This is just as true for those providing health care without regard to the ability to pay, like community health centers, as it is for practices caring for a largely insured population. At health centers such as ours -- Erie Family Health Center -- we look for innovative ways to soak up the cost and we rely on winning competitive federal, state and local grants.

But our doctors, nurse practitioners, certified nurse midwives, physicians assistants, and dentists all have the same stress and challenge of trying to do everything, every day. We clearly need to invent something new.

END OF POST. THANK YOU FOR READING.

Election Landslide in Long Term Health Facility

I have the honor of providing health care to 2 ladies who reside in a local long term health care facility (aka nursing home). Ms Trawler (not her real name) used to be my patient when she lived in the community near our health center. About 10 years ago, she could no longer live by herself. All alone, except for a disinterested niece in the north suburbs, she began falling, forgetting to take her medications, and ended up in the hospital several times. With no one to look in on her and to help, she took advantage of Medicaid and entered the long term care facility.

Life there is not great for her. She rarely goes outside, and although she walks about with a walker, she is not very mobile. A couple of years ago the facility moved her away from her friends on the first floor, on up to the second floor; that was a million miles away from her delicate social circle. (...continued)


Her health care and her long term stay in the facility is funded by you and me. Medicaid picks up the tab for her daily room and board, her medications, and any special tests she may need. Thank you. This has been going on for almost 10 years. Ms Trawler thanks you too.

Her single room is shared with 3 other ladies in various stages of decline. They come and go, hooked and unhooked to various machines, but Ms Trawler stays. And keeps staying. With no privacy to speak of, she has permanently swallowed her pride a long time ago. One bathroom for all four.

So I asked her if she had been able to vote in the election last week.

Yes, of course. They wheeled us down to the basement and we all voted. We always vote.

Ms Trawler is an 83 year old white woman. She grew up in an all white neighborhood where newly arrived Italians lived side by side with immigrant Poles and other Eastern Europeans in Chicago's West Town Neighborhood. Later, Hispanics moved in. She always remarked at how much the neighborhood had changed.

Thus, it surprised me when she told me she had voted for Mr. Obama.

Why, I asked?

Well, he reminds me of why I voted for Jack Kennedy. His family reminds me of Jack Kennedy, his beautiful wife and those two adorable girls. And he's so smart. Everyone else there voted Obama too.

Her choice seemed color blind, from her dreary bed in a musty long term care facility in Chicago. A landslide there for Obama.

END OF POST. Thank you for reading.