Tonight marked the halfway point of the UCSF Mini-Med School on Health Reform. Dr. Diane Rittenhouse continued the argument for better primary care as a main strategy for improving health outcomes, which Dr. Tom Bodenheimer advanced last week. Until primary care physicians are paid as well as specialists like radiologists or urologists, it will be an uphill battle to entice new physicians to enter the branch of medicine that treats patients most holistically.
Bravely, Dr. Rittenhouse defended some of the managed care practices of the 1990s that made insurance companies the targets of much villification. She acknowledged the excesses of managed care, such as sending new mothers home from the hospital 24 hours after giving birth. But on the other hand, managed care was an attempt to apply evidence and standardization to the health system. During the height of the managed care era, she argued, medical costs rose more slowly than usual and more new doctors were drawn to primary care.
The problem with managed care was that insurance companies served as the gatekeepers into the health system, not physicians. Some principles may have had empirical validity, but an insurance company rep was the absolutely wrong messenger. Physician groups are now embracing a similar framework as managed care, for the same purpose of lowering costs and ensuring more consistent treatment. But as health providers they have a sense of the human stakes at a far more acute level than the insurance man ever did.
The upshot: in recent years many doctors have organized themselves around the concept of the Patient Centered Medical Home. This "home" is a metaphor for several good things: personal physicians whom patients actually know; coordinated care across a system, with ready access to relevant patient information; access to care in a convenient fashion; and payment reform that reinforces the role of primary care. Just this week Dr. Rittenhouse co-authored an editorial in the Journal of the American Medical Association that describes the benefits of this system, and the challenges of making it happen.
She closed with those challenges, cautioning that the ever-strange politics of health care could derail meaningful reform. President Obama has publicly stated his commitment to greater primary medical care, which means that specialty medical organizations are already attempting to re-cast themselves as primary care organizations. There is also the very real and enduring problem of ensuring interoperability between different electronic medical record systems. Even if that miracle occurred, it's not clear what incentives doctors who are close to retirement--many of whom still have paper notes and might not have computers at the office--would ever have to participate in such a system.
As ever, much work remains to be done. At least Dr. Rittenhouse pointed the way toward a solution, however challenging it might be to achieve.
"The problem with managed care was that insurance companies served as the gatekeepers into the health system, not physicians"
This is such a true statement. As a Health Services Provider. I have spent the past 20 years in dealing with this uphill battle with insurance companies. While there has been improvement, I have spent many hours educating phone contacts on Mental Health needs and even terminology..I confess. It has gotten a bit old and I find I work at seeing the humor. At the risk of sounding jaded, sometimes that is a tall order.
Good post Marcus
Linda
Posted by: psyche543@aol.com | May 23, 2009 at 11:29 AM