Sunday, September 28, 2008
Primary care, Paul Grundyd- The “Disintermediation” of Primary Care
“ Disintermediation”– The elimination , i.e., wholesalers and retailers, between producers and consumers. The diversion of funds from lower yield to higher yield areas.
I prefer short words to long ones. One hallmark of good writing is short words.
But when it comes to health care, “disintermediation” is an exception. “Disintermediation,” a 7 syllable 17 letter mouthful and mindful, is the perfect word for what has happened to primary care.
Primary care doctors have been cut off from direct human
contact with patients as the traditional source from whom ordinary citizens gain information, sympathy, compassion, and above all, context about their health.
This has occurred, often insidiously, in these ways.
• In most medical schools, primary care is a poor step-child to specialty programs. Specialists dominate the faculty, specialists get the grants, specialists are perceived to be on the cutting edge, and specialists command respect of the medical students, who learn early on that the specialties are where the glory and the money are. They learn pay-off reside in ordering and performing high tech procedures, rather than human interaction, listening, and questioning. They learn transactions not time spent are the essence. They become technicians rather than physicians.
• The coding system “disintermediates” primary care and tilts towards specialists, for the system rewards procedural transactions over time spent with patients, coordination of care, comprehensive services. Things important to patients – being seen on the day one calls, prompt responses to phone calls and emails – are not reimbursed and become secondary. When one realizes that some generalists spend as much as 1/3 of their time on the phone, this oversight is ridiculous.
• The legal system “disintermediates” primary care and rewards specialists because it is based on the premise that doctors should leave no stone, and no specialist consultation, unturned. The typical primary care specialists dreads that moment in the court when the malpractice attorney, asks, “Why didn’t you order a CT scan doctor, when you know one cause of a headache, no matter how rare, might be a brain tumor?” Or “Why didn’t you order that C-section, when you know prolonged labor deprives the baby of oxygen and cause cerebral palsy.”
• Managed care “disintermediates” the primary care physician because it steps in between the doctor and the patient through utilization review and second guessing and because it disregards personal relationships and instead focuses on the “network,” on anonymous “ and algorithm-driven ranking of providers who comply and offer services at the lowest price. As one doctor told me, “You know, Dick, it doesn’t pay to be a good doctor anymore. You’re just another number on the spreadsheet.”
• Direct-to-Consumer Advertising of drugs and medical devices “disintermediates” the doctor because it makes a direct pitch to patients without going through the doctor. Sure, the DTC advertisements always say, “Ask your doctor,” but only after making a direct, and
sometimes often misleading pitch based on the perceived prevalence of a condition. I often wonder how prevalent “ED” is among those handsome young men and lovely young women displayed on the TV ads.
• Perhaps the biggest “disintermediator” of them all is the Internet. The appeal of the Internet is that it cuts out the human intermediary in seeking information. In business terms, it shortens the “supply chain.” Instead of having producer + supplier + wholesaler + retailer + consumer, you have producer + consumer. You remove the human intermediary, the expense of distribution channels and retail outlets. This makes business sense, but it cuts out traditional channels, such as the need for a primary care physicians, to interpret and filter the information are removed. One can always use the phone and consult the “menu,” another ways of eliminating human interaction. One can become one’s own doctor. I realize the efficiencies of such a model, but something is lost in the process, including a personal relationship with a physician who can put things in context based on experience rather than on one’s personal concerns based on one person’s perspective. There something to be said for the old adage that those who treat themselves have fools for doctors. The world may be moving on Internet time, but that time may be too fast for some.
The Ultimate Irony
The ultimate irony of the “disintermediation” problem for primary care is this.
To “remediate” themselves with patients, to reconnect, primary care doctors are turning to the Web, usually in the form of electronic medical records, as a powerful tool to offer prompt, friendly, patient-responsive, educated, best-practice-based, coordinated, and comprehensive care