Regional
(2009-09-21)
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GREELEY, CO
(KUNC) -
Overhauling the nation's healthcare system will once again be front and center on capital hill this week. Not wanting to put the cart before the horse - KUNC commentator Dr. Marc Ringel has been wondering what life would be like if a bill is passed.
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What if we were to wake up, after a long sleep (hopefully not as long as Rip Van Winkle's) to find, thanks to legislation passed by an enlightened Congress, that every person in the United States now has health insurance? How much better would things be for the average citizen? Better, to be sure. But still far from perfect.
The problem is that there simply aren't enough doctors to take care of everybody. There may even be sufficient docs, in terms of a gross measure like physicians per capita, but there aren't nearly enough generalists to give a large chunk of the population what they really need, which is a medical home.
"Medical home" is a new term for the old concept of a usual place for care. It's the place where they know all about you and your health. In olden days this role was served by your family's general practitioner and his staff. The doc who'd delivered you also gave you your baby shots, took care of your ear infections, saw you through your own pregnancies, treated your hypertension, and led you and your siblings in the discussion about when to put Dad in the nursing home.
Now, more than ever, there is always a sub-specialist who does know more about any particular medical problem, from skin rash to chest pain, than a generalist physician does. Trouble is, none of these sub-specialists is likely to know as much about you and your family. For most every diagnosis, you've got to understand the patient in order to know best how to treat him.
A study, summarized in the September edition of "Research Activities," makes the point about the importance of a medical home. Surveys of 2681 Oregon food stamp recipients, found that, with or without health insurance, children who didn't have a usual source of care had double the level of unmet medical needs and seven times the likelihood of no doctor visits in the preceding year. Not surprisingly, the numbers are about twice as bad for kids without a third party pay source.
People with a medical home, not only get more care and are happier with it, but there is an enormous literature that shows they do significantly better medically, especially in terms of avoiding illness through preventive care and staying well through careful management of their chronic disease.
It costs less too. People and payers benefit enormously from belonging to a place that will: take care of their most immediate problems; see to it that recommended screening like mammograms and cholesterols get done; keep up immunizations; make appropriate referrals; coordinate care among specialists and institutions; and monitor and adjust therapy over the long-haul.
Unfortunately, our non-system is so rife with incentives that reward high-priced heroic interventions, like reaming out coronary arteries by cardiologists, over the unglamorous measures taken by practitioners at the medical home, who understand how to get their patient to keep taking blood pressure medicine that reduces the risk of heart attack.
You betcha, we need to get everybody insured. But that's only half the job. To make things better without breaking the bank, any health reform must build in incentives that move healthcare organizations to provide medical homes for their patients. We're already a couple of decades late in getting enough generalist professionals--among doctors that's family physicians, general pediatricians and general internists--into the training pipeline to host all those usual places of care, so we'd better get busy at that too.
If you recall the story of Rip Van Winkle, it wasn't so bad for him to have slept a century because his snooze allowed him to outlive a nagging wife. Sometimes I wish I could sleep through our current mess. Things have only gotten worse over the course of my 40-year career. I pray that we will wake up from this healthcare nightmare before another 60 years pass.
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