PPF: PCP Q&A

Wednesday, July 22 2009

This post is the Q&A follow-up to my previous post, on the primary care panel at the PPF event last week. I mentioned before that I felt the questions for the “Putting Patients First” panelists were pushing for conservative answers. You will now see this in several of the questions Rea Blakey asks; of course, my kudos to the panelists for pushing back against her framing on several of the issues.

And let me say again, I am paraphrasing from my woefully incomplete notes; nothing here should be taken as a direct quotation, even if it appears in “scare quotes”. ‘Single quotes’ simply indicates what I wrote down in my notes, which could still be inaccurate. (I’m putting my comments in parenthesis, because these are not things I actually got a chance to say at the event). Confused yet? Give it time.

The PCP panel directly followed Congressman Ryan’s speech and exit, so Ms. Blakey ‘s first question was, ‘What will you blog about regarding Congressman Ryan’s remarks?’ Kevin answer that the difficulty is, how do you cover everybody and control costs? We have to do both. Kevin said that the answer isn’t “rationing”, but ‘judicious decisions’. He said ‘we need to make better decisions.’ Dr. Dappen remarked on the ‘tidal wave of cost’. He said that nobody focuses on cost, but it’s ‘not one thing’. Dr. Dappen pointed to several things: malpractice, dumb consumers, defensive medicine, insurance keeping the money…. Dr. Rob added that the ‘patient is a piñata’.

Dr. Dappen stated that market solutions would help health care; in the present system ‘nobody can compete’ if there’s ‘only a $20 co-pay’. Dr. Dappen said ‘we are all part of the solution’. Dr. Rob compared health care to a ‘ship sinking’ – and said ‘we’re arguing over who is going to be captain’. He said it’s distasteful that a physician can make more money in cosmetic surgery. (I would point out that cosmetic surgery is more or less a free market; I am not aware of any health insurance plan that pays for elective cosmetic surgery, much less any government program that does so. For all the talk about the efficiency of free markets, there are still plenty of sagging breasts, crooked noses, and bald spots in this country. I leave to the market’s advocates to explain how it will know to treat the ill any better than it does the homely.)

Ms. Blakey then paraphrased the bit from Rep. Ryan’s speech where he says that in a government-run system, “…currency in this power structure is political connections, interest group politics, and bureaucratic dictates”; she then asked, how do we get to a system driven by value? Kevin said that actually, none of the proposals in Congress is really for a government-run system (thank you, Kevin, for pushing back). Then Kevin talked about the Atul Gawande article, and argued that we have to ‘change the system to encourage doctors to spend time with their patients’.

Ms. Blakey then asked Ms. Tinley whether it was difficult for NPs to innovate in their practice. Ms. Tinley replied that it was very difficult, that there were too many patients. She said that what we need is ‘patients who understand cost’. Dr. Rob added that he joined the blogosphere primarily to talk about EMR (electronic medical records); he uses EMR in his practice and it helps him to be very profitable. Dr. Rob said his EMRs allow him to pay attention to the patient, to track vaccinations and problems and so on, but there are some problems with the idea of “value”. He said it’s very difficult to measure quality, and the only people doing so are insurance companies; do we trust them? We have to define what quality is, and CER is important; do these things work? Dr. Rob said that only when you define and measure quality can you say what value is.

Ms. Blakey then asked whether physicians are sidelined. Dr. Dappen said yes, and that the ‘AMA does not speak for trenches’ (this was just on the heels of the AMA endorsing the President’s reform agenda). Dr. Rob pointed out that the fact of his presence at the event meant he was losing money, and it’s very difficult for practicing physicians to participate in these debates; ‘blogging finally made me feel like I have a voice’.

Ms. Blakey then pointed out that she doesn’t trust the Hill, and asked what providers can do to get more involved. Kevin pointed out that physicians are not on the same page; there are too many different organizations. They ‘need to speak with a unified voice’. Dr. Rob said that doctors are ‘not in the equation’, and re-emphasized the theme of ‘Putting Patients First’ – that this was ultimately about a relationship between two people in an exam room. (Personally, I think there’s a lot more to health care than what happens in the exam room, but Dr. Rob has earned some latitude.)  Dr. Dappen said that doctors ‘are obliged to stand up for health care’, but are ‘sitting back too much’. Ms. Tinley recommended that Mr. Ryan take a look at the video on Better Health (maybe this video?). She also suggested that Virginia has seen an increase of 99% in insurance and medical costs from 2000 to 2007.

The next question came from the audience; a woman from the National Health Council said their motto is also “Putting Patients First”, and that they represent 133 million people with chronic conditions. (I would point out that NHC is rife with pharmaceutical company money, so whatever they might be saying for the 133 million of us with chronic conditions, they are also saying it on behalf of the pharmaceutical industry, among other non-patient interests.)  She asked whether the panelists had looked at the Geisinger system. Kevin replied that large plans like Geisinger and the Mayo clinic have been shown to provide excellent care at low cost, but the question is how to integrate smaller practices to acheive the same benefits. Dr. Rob said that computerization is the answer, that he can track outcomes across all his patients, but that ‘you can’t have commerce until you have a system’; you need to collect data.

Dr. Perry Hookman, also from the audience, argued that single-payer is inevitable, as is a two-tier system with VIP concierge medicine on top, and everyone else on the bottom – so how is this going to work? Kevin said this might happen if reform collapses, but that we need to focus on cost. Dr. Hookman said that states have to balance budgets, but the Federal gov’t can print money, can spend it on space weapons, AIG; he asked, can’t America take care of its people? Dr. Rob said the problem is cost, and pointed out that we pay for things like 90 year old Alzheimer’s patients with DNRs to get treated in the ICU.

That was the end of the questions; it was an interesting discussion, and it elicited some useful information from the panelists. In particular, I think the best part was listening to Dr. Rob recite his struggles with hospitals and other providers – not for the struggles themselves, but because his stories echo the difficulty I have had with my own primary care. He’s right – they’re all right. Primary care is in crisis. It was clear from this panel – even through a dim haze of ideological cant – that if we’re ever going to craft a just and efficient health care system in this country, primary care needs to be a priority.

Tags: care, docs, ppf

Leave a Reply

Name: (required)

Email: will not be published (required)

Website:

Comment: