Your Voice: Primary care must be the “bedrock” of healthcare

Dr. Keller expresses a great deal of frustration with the MACRA legislation (“Your Voice,” Medical Economics, February 10, 2017). Rightly so-it is a bureaucratic tangle.

That being said, I have to take exception to the idea that the medical industrial complex (hospitals, pharma, drug device companies and doctors) has truly given a good deal to the American public since Medicare was enacted in 1965. Keller writes, “traditional fee-for-service Medicare provides excellent medical care and is preferred by both patients and by their doctors.” Does it, really? It may be “preferred,” but at what long-term cost to our way of life?

Large swathes of our population only now, with the ACA, have access to any medical care. Over 35% of our population is obese and thus at increased risk for heart disease and cancer. Substance abuse is decreasing the lifespan of large parts of our society. The cost of U.S. healthcare is devouring 18% of our multi-trillion gross domestic product with no end in sight. Our children and grandchildren will pay dearly in the form of higher taxes and a lower standard of living to fund this debt.

Society must demand better outcomes in healthcare. How many unnecessary procedures and tests are done in our country in the name of “excellent medical care,” only to lead to poorer outcomes and wasted resources?

We need to incorporate the best ideas from all industries that have improved levels of efficiency and value while managing costs sensibly. We must incorporate more evidence-driven medicine in day-to-day care and our public health initiatives. We need to make primary care medicine the bedrock of healthcare in our country. We need more scientific thinking and less politics and emotion.

 It is not about single payer or taking the profit out of healthcare or the cheapest short-term solution. It is about value which focuses on cost, the patient experience and measurable outcomes. It must operate on all levels of the healthcare system-from the office to the hospital to the community.

We have a lot to do and we are running out of time. 

Titus Abraham, MD
Annapolis, Maryland

MACRA's massive bureaucracy

Dear Dr. Abraham,

Thank you for your thoughtful reply to my letter condemning MACRA. Clearly, all physicians want the best for their patients, and the debate over how to achieve that goal should be decided by clinicians, not lawyers or MBAs.

My opposition to MACRA is based on the massive increase in bureaucracy, documentation and regulation of medical practice that this pernicious law will introduce. MACRA will not and cannot save money for Medicare, because seniors will still need the same number of clinical services, such as hernia repairs and cataract extractions.

Every unit of physician time spent complying with the new documentation requirements will raise the overall cost of care, stealing money that could be paying for knee replacements and aorta repairs. I don’t need a bureaucrat to fine or reward me for how I treat diabetes, hypertension or hyperlipidemia. Doctors attend medical school and residency and CME classes to learn our skills, and now we recertify every decade as well. We know the science and we know the patient. If good medical care could be provided by a checklist, we could save a lot by replacing doctors with a clipboard, plus or minus a bureaucrat.

We have seen fewer pneumonias due to one proven quality measure, pneumococcal vaccination, but that was achieved before MACRA. We are now seeing the opposite problem: Seniors are getting unnecessary repeat vaccinations, because no provider wants to take the chance that they will get dinged for not vaccinating an eligible senior. Trust the primary care doctors - that is our job.

Fee-for-service is not why prices exploded. Healthcare is expensive. Treatments like immune checkpoint inhibitors for metastatic melanoma are miracle drugs, but the cost to develop them is in the billions of dollars. Yes, screen for primary melanoma, but you can never prevent all metastases. Is there a worthier way to spend our money than to offer a young patient with metastatic melanoma a real chance for cure? You bemoan the 18% of GDP we spend on healthcare. We spend almost the same on the military to fight endless, pointless foreign wars that never justify the lives lost or the debt incurred. 

Yes, we should incorporate scientific evidence into our everyday medical practice. This may surprise you, but a well-designed study published in BMJ (bit.ly/medmal-resources) found significantly less risk of malpractice by doctors who order more diagnostic tests. Clearly, doctors should not blindly order unnecessary tests. But this study provides evidence that MACRA should not penalize doctors who order tests more frequently than their peers. The number of tests a doctor orders should be revenue-neutral. Penalizing doctors who “order too many tests” is degrading to us as learned professionals,
and is truly unscientific.

The Affordable Care Act must be maintained until we develop a better way to fund medical care for those who need it. Medical care for everyone is beyond debate. I oppose MACRA, with its thousands of new intrusive and expensive regulations, precisely because I believe in quality medical care for everyone. Whether you are a doctor or a patient, “traditional Medicare” is the best deal around. The elderly and the poor are our parents and our neighbors, and they deserve great care. Traditional Medicare has a proven track record. Doctors and patients love it, and we can pay for it by not bailing out any more failed investment banks or foreign dictators. 

David L. Keller, MD, FACP
Lomita, California

Medical journals must play bigger role in reform

In “Healthcare reform must start with physicians, not politicians,” (Medical Economics, March 10, 2017) editorial director Keith L. Martin exhorts physicians to take their rightful role in determining what the future of our health care system should look like.

I would argue also that our medical journals have a responsibility in helping physicians take that role but they have let us down.  Why? Because they have the ability to influence policy makers and the media and physicians, but they do not take advantage of it.

Yes, they publish essays and perspective pieces on the need for medical liability reform and insurers’ intrusions. But, they are mostly written by members of the academic community in convoluted prose that as well-intentioned, as they fail to convey the great dissatisfaction that most physicians feel.  

These communications act only as introductions, because they lack the voices of practicing physicians.  From those very physicians who are practicing “in the trenches,” every day seeing patients and dealing first-hand with the many problems inflicted by the adversarial medical liability system and greedy insurers.  Without their voices change, the changes that are needed will be ignored.

For this reason, Medical Economics is to be congratulated, for it is the only national journal that consistently prints articles written by practicing physicians in clear and concise prose that expresses their frustrations and dissatisfaction with medical practice and the changes that are needed.

Medical Economics provides an invaluable forum for all physicians. Because it lacks the complicated and frustrating electronic submission procedures employed by the academic journals, it is easily accessible by all doctors.

This and its editorial policy make Medical Economics an important communication resource for physicians.

The author’s advice to physicians to “...write a letter… make a case and share an insight,” should be committed to our collective memories.

Sharing insights with the written word is the quickest way to jump-start physicians’ solidarity and the courage that physicians need to exert their rightful place in the debate over healthcare reform.

Edward Volpintesta, MD
Bethel, Connecticut