Your Voice: Physicians can save healthcare

It has been clear for many years now that primary care practiced in a truly transformed patient centered medical home (PCMH) practice saves the system thousands of dollars. 

In my own PCMH, we have reduced hospital admissions by 80% over a five-year period, not to mention ED visits. I don’t remember the last diabetic ulcer I have treated because of the good care we give diabetics in our NCQA-certified diabetic center of excellence. I could go on and on about the successes.

Unfortunately, the federal government and large insurance entities are giving lip service to these PCMH settings, but not reimbursing them. There is a significant overhead cost to provide these advanced levels of care, and these highly functioning clinics are soon going to collapse because reimbursement is not supporting their infrastructures.

Every patient in the U.S. should have a primary care physician in a highly functioning medical home-that is how to save the healthcare system. 

We need to be the gatekeeper. How many times have you seen patients on the subspecialty treadmill seeing multiple subspecialty physicians at increasing cost as they order more and more procedures? Don’t order tests if you are not acting on the results. Have frank discussions about end of life issues and aggressively use hospice care in the appropriate setting. These are not “death squads.” This is just good patient care. Twenty-five percent of all healthcare dollars are spent in the last six months of a patient’s life. This has to stop.

I also am quite cynical about the MIPS payment system. The point total for reimbursement will be heavily weighted toward controlling costs but patients aren’t being penalized for bad choices. They will still be able to go to any hospital or any ED whenever they chose to do so.

We as physicians will be the losers in this system being negatively reimbursed for poor patient decisions. The rest of the point system we can manage without difficulty. Reimbursement should be giving incentives to physician practices for good care. Aren’t decreasing hospital admissions by 80% enough to prove you are practicing cost-effective medicine?

I concur completely about asking physicians how to design the system. Don’t go to big insurance entities, big pharma and big hospital systems to redesign the systems. It is the physicians and their ancillary personnel who understand how the system should work. 

Build the system around a strong primary care workforce. This has been proven over and over again in other parts of the world. Cut out the special interest groups and lobbyists in the federal government and do what is right for a change. This may be the last time we have an opportunity to do this in a long while.

Ed Bujold, MD, FAAFP

Granite Falls, North Carolina

Patients, payers need to be held accountable

There are numerous problems plaguing our healthcare system today. Two with the most adverse impact from my perspective are the exorbitant costs that insurance companies charge patients in premiums and the other is medical malpractice. 

It is not right that insurance companies are making millions of dollars on the backs of both patients and physicians alike. I view them as middlemen taking money in the form of premiums from patients and then passing onto the healthcare providers a mere fraction. They “nickel and dime” us for everything. This is most apparent, in that nowadays most independent physicians must incorporate some form of alternative/cosmetic practice in order to keep their traditional practice afloat.

It is equally unfortunate that no one in the past decade seems to be interested in medical malpractice reform. We all walk on eggshells at the thought of being sued and because of this, we practice “defensive medicine” and completely over-test patients to try and protect ourselves from a lawsuit. This drives up costs unnecessarily for the whole healthcare system. 

A panel comprised of doctors, lawyers and laypeople should be developed to assess whether or not a filed lawsuit holds any merit. The ability to file a lawsuit should never be taken away from patients, but the reality is that the frivolous lawsuits make up the vast majority of these suits.

Lastly, patients need to be accountable for their own health. There are way too many patients out there who do not follow good health practices. Some of them smoke, don’t exercise and eat nothing but junk food despite being counseled on the tremendous health benefits to the contrary. 

They are a huge financial burden to the entire healthcare system and everyone else ends up paying for their care. It is not right. Patients need to be held financially accountable for their own health especially if they are not engaging in a healthy lifestyle.

Well, I could go on forever about all of these healthcare “ills” but I have to go see some patients now and practice real medicine.

James P. Clancy, MD
Chicago, Illinois

Reforming healthcare means addressing unrealistic expectations

I had to smile when I read “Healthcare reform must start with physicians, not politicians” (Medical Economics, March 10, 2017), and the line about “time to take the wheel.”

We’ve been trying unsuccessfully to do that since insurance companies decided that the patients were theirs and not the doctor’s. I’m not sure we are even in the car, much less driving. But let’s talk about healthcare.

If the goal is to provide great care at a lower cost, let’s begin with the elephant in the room that no one talks about but will prevent any system, even a single payer, from reducing costs-patient expectations, or more accurately unrealistic patient expectations (UPEs). 

UPEs are where patients expect physicians to be correct 100% of the time, that all surgery will be without complications, that all infections require an antibiotic, that life should be pain-free and that all disease has a cure. The end result is massive costs for defensive medicine and pharmaceuticals. Then, we have the UPE that doctors can fix them despite their lack of self-care in the forms of cigarette smoking, sedentary behavior and obesity.

 Then there is the big UPE: That doctors can and should prolong life regardless of how sick the patient. Americans do not accept the inevitable and we pay dearly for that mentality. Anytime there is talk of withholding care the term “death squad” arises and the discussion ends. 

In our country, we have significant social drivers which, unless first addressed, will prevent any change in our healthcare system from reducing costs. It does not appear that politicians or physician leaders want to drive this car. 

Steven Howard, MD
Belmont, California