Map of life expectancy at birth from Global Education Project.

Wednesday, March 26, 2008

If you got the time . . .

This morning we heard from Dr. Kelly Kelleher about how it's a great idea for primary care doctors to screen for alcohol and other drug abuse problems. There are, however, some difficulties.

Every disease advocacy organization in the world wants primary care doctors to be screening -- for asthma, diabetes risk, cancer, depression, domestic violence, you name it. In fact there are something like 700 questions that primary care docs are supposed to be asking their patients. However, they generally see 4 or 5 patients an hour. Since the patients are presumably there for some reason other than to be asked the first 30 or so of 700 questions, it's unlikely we're going to get very far with that.

And then, suppose the doc identifies an adolescent with a so-called "substance" abuse problem? ("Substances"? Puhleeze. The reason for this bizarre locution is that we aren't allowed to call alcohol a drug of abuse. Because they have a lobby.) What to do? Generally, no idea. The primary care doc does not get paid to do any counseling about this herself, if she has any idea how to do it in the first place. And no, they don't teach that in medical school, or in your residency. Referrals? Maybe something is available, maybe not, but then do you have to tell the parents? What if the kid doesn't want you to? If you do refer the kid, will he go? Answer: no.

So, they're trying all sorts of high tech solutions with computer-based screening tools that upload data to central registries that dispatch social workers whenever the light blinks red. Who's going to pay for that when the study grant runs out? Answer: nobody.

Here's the bottom line, for me. Primary care physicians have a lot of important jobs to do, that they aren't paid to do, and therefore they don't get done. If insurers started reimbursing primary care physicians to spend time talking with patients -- and it could be very structured, so that specific, well defined, evidence-based screening and counseling services are being delivered and evaluated, and the docs are trained to do them -- we'd have more people going into the primary care specialties, they'd be happier in their jobs, they'd have more prestige, they'd spend more time with patients, and we'd have a healthier population. We'd also need to reimburse primary care practices for important ancillary services such as case management and disease management programs. All this makes tremendous sense in long-term social cost-effectiveness as well. So why doesn't it happen?

Because it doesn't make sense in terms of short-term cost effectiveness for the individual payer. If a health plan starts paying its primary care docs to identify more patients who need services that cost money, it's out of pocket for now. Even though it's relatively little money, and it's going to prevent much more expensive problems later on, by the time those expensive problems emerge, the person is probably not going to be a member of the same health plan any more. So somebody else will have to pay for it.

If we want to do all these great, progressive, sensible reforms of the way we deliver health care, we need:

Universal, Comprehensive, Single Payer National Health Care.

That's the only way.

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