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Editorial
Ten Hard Questions About the Future of the Specialty

Posted 09/30/2005

Douglas Iliff, MD

The Future of Family Medicine reports left some key questions unanswered.

Introduction

Although my practice is thriving, it's hard to escape the conclusion that my specialty is not - and this despite my conviction that family-centered, longitudinal, preventive-oriented medicine is the best model for most patients and our health care system. For many months, I have been cautiously hopeful about the Future of Family Medicine project. I found much to praise in the initial report, despite its overly idealistic and academic tone.[1] However, I questioned two unexamined postulates of the project: that American health care consumers respond to the quality of the product rather than the price, and that American health care payers respond readily to long-term quality rather than short-term costs.

As I awaited the Task Force Six report on financing the New Model of family medicine, which I considered the linchpin of the entire initiative, I formulated the following questions and, where possible, my own answers:

1. Why is it easier to fill training slots in gastroenterology, radiology, ob/gyn or orthopedic surgery than family medicine?
   
   Since the vast majority of medical school applicants profess a longing for primary care, the most tenable answers are (a) the influence of mentors and (b) monetary rewards. I choose (b) as the cause and (a) as the rationalization.
2. When family physicians have committed to electronic medical records and evidenced-based practice, and research is humming along at thousands of small laboratories, will the demand for prestigious family medicine training slots exceed supply?
   
   In this imaginary scenario, the quality of family medicine will be the highest in history, but family physicians' income will have shrunk still further due to unreimbursed technology costs and continuing reductions in health plan reimbursements. Students will therefore tender their admiration for family medicine and request a colonoscope for graduation.
3. Will Medicare, Medicaid and insurance companies, recognizing the cost savings of family medicine, reimburse cognitive services on a par with procedures?
   
   When hell freezes over.
4. Since every new screening test, drug, procedure or technique trumpets its global cost-savings, why is the cost of medical care once again spiraling out of control as managed care wanes?
   
   Those are wink-and-a-sneer confabulations, and we all know it. Coreg vs. atenolol? TPA vs. streptokinase? Plavix vs. aspirin? Most modern drugs offer a 5 percent increase in efficacy at a 1,000 percent increase in cost, and we must remember that 86-year-old nursing home residents now receive triple-bypass surgery and hip replacements on demand.
5. Does controlling medical inflation involve somebody making a cost-benefit decision and saying "no" to a test, drug, procedure or technique? If so, who?
   
   Yes. Government, insurance companies, physicians or patients. Any volunteers?
6. Under whatever form of universal health care envisioned by the AAFP, who would make the rationing decisions?
   
   Perhaps Task Force Six would answer this one, I thought.
7. When universal health care is operative, does the Academy imagine that it will muscle family physicians to the front of the reimbursement line more effectively than under the present system?
   
   Here's another one I couldn't answer.
8. Why do my patients, who have had the benefits of open-access scheduling, office staff who know them as friends as well as patients, and a doctor who has always provided the "medical home" advocated by the Future of Family Medicine, leave this practice due to a change in insurance that might cost them an additional $5 or $10 per office visit?
   
   American consumers are exquisitely price-sensitive. I think my patients truly appreciate the "home" we provide, but not as much as they appreciate the $5 or $10. This is not to say they couldn't be sold on my ability to save them money if they had real money at risk, which almost all insured patients do not.
9. If all cost-benefit decisions were in the hands of patients and those patients stood to benefit financially by wise purchasing decisions, could family physicians compete with other groups of physicians and non-physician providers in a truly open marketplace?
   
   I wish I knew the answer to this one, too. I know I would be eager to compete; I am certain that I effectively handle more problems per dollar spent on my services than physicians in other specialties. Back in the halcyon days of full capitation, I collected several annual bonus checks in the $60,000 to $80,000 range as a share of the money left over in my pool at the end of the year, but many of my family medicine colleagues did not fare so well.
   
   Do we really believe in ourselves, or not? The implications are enormous. If we believe our own propaganda, then we want the patient in full command of the money decisions, as with health savings accounts, because this will produce high demand for our services. If we don't, then we need to vastly increase our contributions to political action committees - in order to shoulder our way to the front of the trough.
10. Believing that we will inspire our patients to make desperately needed lifestyle changes, the AAFP is promoting the untested hypothesis that family physicians should shape up and become better role models. What percentage of patients will be moved to sustained action, lacking any financial incentive or disincentive to do so?
    
    We all know that lifestyle choices are killing our patients. I don't know what works, but I'm pretty sure I know what doesn't. I've been a perfect role model my whole career, right down to running two Boston marathons and winning an AAFP convention 5K. I've preached diet, exercise and smoking cessation for three decades. Out of 4,000 active patients, at least 400 are in desperate need of overhaul; I pioneered and extensively publicized a program called Basic Training (http://www.iliffbasictraining.com), and six patients signed up (none of them were among the 400 I targeted). In one form or another, we've all tried wheedling, cajoling and pleading. Personally, I think it's time to hit them in the wallet. Only health savings accounts, among all the ways of financing health care, bring the full bore of moral hazard to bear on this desperate situation.

Section 1 of 2
Next Page: Afterthoughts
Dr. Iliff, a family physician, has been in solo practice for 19 years in Topeka, Kan.

Conflicts of interest: none reported.

Fam Pract Manag. 2005;12(8):14-21. ©2005 American Academy of Family Physicians

__________________
Mr. Jan B. Wade
Blood Management Consultant
Enhance Outcomes - Control Cost
For Information Call - 360 296-1807
Email

http://www.medscape.com/viewarticle/514071?src=mp

Flood-Damaged New Orleans Hospitals to Be Closed


WASHINGTON (Reuters) Oct 05 - Charity Hospital in New Orleans, which captured the sympathy of the nation as it struggled to evacuate patients from the chaos and destruction brought by Hurricane Katrina last month, cannot be saved and will be closed, officials said on Wednesday.
The Louisiana State University Health Care Services Division said the Charity and University Hospitals were too heavily damaged and were unsalvageable.

"The... Charity and University Hospital buildings were issued their 'death warrant' by Katrina and the cataclysmic floods it spawned," said Donald Smithburg, chief executive officer of LSU's Health Care Services Division.

"Even before the storms, these old facilities were on the ropes," he added in a statement.

Charity Hospital was built in the 1930s and University Hospital in the 1960s.

As levees failed and New Orleans filled with floodwaters after the hurricane, doctors at Charity called television networks and newspapers on their cellphones, begging for help.

They described watching in disbelief as staff and patients at neighboring hospitals were evacuated while they waited amid growing desperation and danger.

Staffers eventually were forced to beg rides on boats and in military vehicles to get their dying patients to a nearby helicopter pad for evacuation. Some would-be rescuers were frightened off by reports of gunfire, which in many cases turned out to be false.

Smithburg estimated that damage to Charity Hospital totaled more than $340 million and $105 million at University Hospital.

Only three hospitals are now operating in New Orleans -- East Jefferson, West Jefferson and the Ochsner Clinic. All are not-for-profit hospitals in the immediate suburbs.

Charity was the only free hospital in New Orleans and doctors have expressed fears that poor patients will go untreated while a replacement is built, a process that will take years.

In the meantime, the USNS Comfort, a naval medical ship, will help. The ship, which is already receiving patients, is docked at the Poland Street Wharf, adjacent to New Orleans' badly flooded Ninth Ward.

It is a trauma facility with 12 fully-equipped operating rooms, 1,000 beds, X-ray equipment including a CAT scanner, a medical laboratory and a pharmacy.

Smithburg said that despite an effort to clean up Charity Hospital, it could not be used again to treat patients. "Both facilities are dangerous, dangerous places," he said.

"Over the past several weeks experts have inspected both hospitals. Perhaps to the well-intended observer the facilities don't look much worse than they did pre-Katrina, but through the lenses of consulting engineers, the buildings have unsafe air to breathe, pervasive mold growing, and mechanical systems that were completely destroyed by the storm."

__________________
Mr. Jan B. Wade
Blood Management Consultant
Enhance Outcomes - Control Cost
For Information Call - 360 296-1807
Email