Thursday, June 25, 2009

Costs, Data-Driven Care -The Office Visit as Health Cost Saver: Another Untold Story

During the health care debate, you will hear a lot of talk about how to save money. President Obama has three main strategies – stressing prevention to avert chronic disease, installing interoperate medical records across the land in health facilities, and coordinating and offering comprehensive care through medical homes or primary care physicians.

What you don’t hear is that much of the cost occurs because care is offered outside primary doctors offices - in specialists offices, in emergency rooms, hospitals, specialized diagnostic and treatment facilities, and hospitals.

I became acutely aware of the magnitude of cost differences in an interview I conducted with Jerry Reeves, MD, chief medical officer of the Hotel and Restaurant Employees International Union (H.E.R.E.I.U) located in Los Vegas, “Data-Driven Health Care: An Interview with Jerry Reeves, MD, June 8

Jerry’s argued was the point of entry of patients into the system – where they are seen and treated – makes a tremendous difference in costs.

Point of Entry of Patient – Cost per Disease Episode

Hospital $9363
Emergency Room $737
Urgicenter $64
Private Office $69

In Jerry’s study, conducted in 4 cities around the country, stunned me. Jerry said his union had made a systematic effort to persuade their members to be seen in physicians’ offices rather than in other settings. He said doctors received 6 times more payment for administering chemotherapy in specialized facilities than in their offices.

Why should this be? Well, in the first place, facilities outside of medical offices have a much higher overhead. Secondly, regulations may be more stringent and expensive. Thirdly, facilities can charge a “facilities fee,” made possible by government mandate. For these and other reasons, including the fact they must be open 24 hours a day, hospital fees are much higher.

So why is this fact not more widely recognized as a huge factor in health inflation? And why is nothing being done about it? There are a host of reasons, including.

• By law, hospitals are obligated to take all comers, and patients know this.

• Hospital ERs are open 24 hours. Patients know this, and many don’t want to “bother” their doctors at night, weekends, or off-hours.

• Primary care doctors are in short supply, and waiting times to see them are 20 to 50 days depending on the city.

• One of five Americans is a recent immigrant, may not be a citizen, and may not understand how to access a private physician.

• Roughly 47 million Americans are uninsured. These citizens may delay treatment, may have negative lifestyle, and may not seek care until they are seriously ill and require hospitalization.

So what are the answers?

• Publicity campaigns apprising the public and health plan and union memberships of this information.

• More care provided in less costly settings – urgicenters, cash only practices, retail clinics.

• Incentives and national programs to induce more medical students to enter primary care careers (general internal medicine, family practice, pediatrics.
Strategies to “revitalize” primary care include.

One, Payment reform. Increase primary care payment under the Medicare fee and health plan fee schedules.

2. Pay primary care doctors for phone calls and email requests.

3. Medical student debt relief for choosing primary care.

4. Change in the way primary care is reimbursed through the festering of medical homes centered on patients.'

Two, Investment in primary care infrastructure and organization.

1. Investment in health information technology for primary care.

2. Creation of nationwide system of primary care extension agents to assist practices in making improvements,

Three, Attracting more U.S. medical statements into primary care

1. Redirection of substantial portions of Medicare graduate medical education funds to primary care residency programs.

2. Increase in funds for Public Health Service primary care training.


sewdarnlucky said...

Why not have all doctors paid for emails and phone calls? All of them are giving their time for these actions. Why should only primary care doctors get paid for the same work?

G J said...

Dr. Reece, there's a book's worth of story in the theme you've presented here, capsulized in the data you cite from your interview with Jerry Reeves.

I'll even provide you a title: "Wither Health Care? The Toxic Geography of US Medicine"