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KevinMD Addresses Crowd At National Press Club About Primary Care Crisis

The following are my prepared remarks at Health Care Reform: Putting Patients First, held at the National Press Club in Washington, DC, on July 17th, 2009.

President Obama recently declared that, “We are not a nation that accepts nearly 46 million uninsured men, women, and children.” And indeed, finding a way to provide universal health coverage to every American is one of the focal points in today’s health care debate. There are a variety of ways we can achieve this, ranging from a Medicare for all, single payer system to requiring everyone to purchase health insurance. But no solution can work unless we first deal with the shortage of primary care doctors.

After all, what good is having health insurance if you can’t find a doctor to see you?

As a primary care physician in Nashua, New Hampshire, a city that borders the state of Massachusetts, I have had the luxury of closely observing that state’s health reform efforts. And to their credit, Massachusetts currently enjoys near-universal health coverage, in part because of the mandate requiring every resident to obtain health insurance. Many policy experts are predicting that a national plan will closely emulate the Massachusetts model, so it’s worth noting any potential consequences.

Since reform began in 2006, the Massachusetts health care system has been inundated with almost half a million new, previously uninsured, patients, and the demand for medical services has rapidly outpaced physician supply. The wait to see a new primary care doctor is almost 2 months, leading patients to use the emergency room more often for routine visits. In fact, since the universal coverage law was passed, Massachusetts emergency rooms have reported a 7 percent increase in volume, which markedly inflates costs when you consider that treating simple conditions in the ER can be exponentially more expensive than an office visit. It’s no wonder that the plan has placed significant fiscal strain on the state’s budget, which is struggling to contain soaring health spending.

This affects hospitals like Boston Medical Center, which primarily serves the city’s poor. The state’s mandatory health insurance law is causing the medical center, according to a front page story in last Sunday’s Boston Globe, to brace “for dramatic financial losses, which some fear will force it to slash programs and jeopardize care for thousands of poverty-stricken families.”

Furthermore, consider the words of family physician Kate Atkinson, who practices in Amherst, Massachusetts. She had decided to temporarily accept new patients, as 18 doctors in her area had recently closed their practices or moved away.

“There were so many people waiting to get in, it was like opening the floodgates,” she says. “Most of these patients hadn’t seen the doctor in a long time so they had a lot of complicated problems. We literally have 10 calls a day from patients crying and begging.”

She closed her practice to new patients 6 weeks later.

I witness this phenomenon myself every day, with patients from Massachusetts routinely crossing the border to New Hampshire looking for a new primary care doctor.  These are people with chronic conditions like heart disease, diabetes, depression, and high blood pressure – all who need a regular physician to follow them.

And keep in mind that Massachusetts has the highest density of doctors per capita in the country. What do you think will happen to states that do not have a comparable supply of physicians?

Moving away from Massachusetts, let’s look at two other examples where universal coverage was promised before ensuring adequate primary care access. One would be our military veterans, who are guaranteed health care through the Department of Veterans Affairs, also known as the VA. Earlier this decade, the wait to see a primary care doctor in the VA routinely exceeded 50 days in various parts of the country. Although that number has improved, a recent report by the Office of the Inspector General concluded that more than a third of veterans still waited a month or more to see a doctor. And with tens of thousands returning home from Iraq and Afghanistan straining an already overburdened VA health system, it’s no wonder that my practice in Nashua, New Hampshire sees a fair amount of veterans who are unable to obtain timely care from their local VA clinic up north in Manchester, or from down in Boston.

Next, consider the care Native Americans receive via the Indian Health Service. Despite having guaranteed health care coverage, President Obama himself cites Indian reservations in South Dakota that have some of the lowest life expectancies in the Western Hemisphere. American Indians are twice as likely to die from diabetes when compared to whites, 60 percent more likely to have a stroke, 30 percent more likely to have high blood pressure and 20 percent more likely to have heart disease. Although each of these conditions can be treated or prevented with timely primary care, according to a 2005 Government Accountability Office report, patient waits within the Indian Health Service for routine women’s care and general physicals lasted anywhere between two and six months.

It is encouraging that the President and members of Congress recognize the threat that the primary care shortage poses to their health reform efforts. But some of the solutions being discussed, such as reducing medical school debt, increasing funding to the National Health Service Corps, and training more mid-level providers like nurse practitioners and physician assistants, fall woefully short. None will have any immediate impact, which will be especially critical if there’s a distinct possibility that already overwhelmed primary care doctors will be responsible for almost 50 million additional, newly insured, patients overnight.

Instead, we need to value primary care, and make it central to our health system. Rather than being encouraged to squeeze in appointments and rush through office visits, doctors need to be incentivized to practice patient-focused primary care, including, managing chronic diseases, providing preventive medicine guidance, and taking the time to counsel patients.

There’s no question that we need to find a way to provide health coverage for every American. But we must do so in a responsible manner, and that starts with ensuring that we have a strong primary care system first.

*This blog post was originally published at KevinMD.com*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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