Poor McAllen, Texas.
The much maligned city has been in the health policy crosshairs ever since Atul Gawande’s seminal New Yorker article on health costs.
Now, it has the added distinction of being the worst place in the country to live with allergies.
The reason? Apparently, there’s one allergist for the entire city. One. And according to this piece in Newsweek, that means more primary care doctors and non-allergy specialists are treating seasonal allergies, and in most cases, inappropriately.
The thinking goes that specialists can pinpoint specific allergy treatment better than generalist doctors, and thus, can better control symptoms than allergy-ignorant primary care doctors:
In the larger health-care debate, it’s common to hear that an easy way to reduce costs is to limit patients’ access to specialists. Send them to primary-care docs instead, the thinking goes, and they’ll get more preventive care and fewer pricey treatments. That’s true if you’re talking about an illness that responds to cheap preventive measures and is only treated by specialists.
Of course, the article cites data from the Allergy and Asthma Foundation of America, which certainly has a stake in the issue.
Expect the argument that fewer specialists actually increases costs to be increasingly made, especially as specialist reimbursements likely will be disproportionally squeezed going forward.
But is it really true? I have yet to see conclusive data supporting that blanket assertion.
Related posts:
- ER visits and health care costs rise in Massachusetts due to lack of primary care access
- Increasing copays will increase costs for health insurance companies in the long run
- When allergies are really not
- Health care costs
- Op-ed: Doctors’ pay cuts save little in health costs
- When specialists provide primary care, and why patients aren’t complaining
- Where’s the money to better pay primary care doctors going to come from?
{ 7 comments }
Specialists are trained to be experts in a narrow field within medicine to the point that they can diagnose and treat with efficiency and precision far better than any primary care physician, knowing the wide range of literature on the subjects to which they devote their careers. Why attempt to manage patients which are not within the physician’s specialty and spend visit after visit trying new things and not succeeding, when a referral out to a specialist could have solved the issue with one consultation? Of course I am being optimistic with this, but there is certainly realistic merit to the article’s hypothesis that specialization can optimize patient management.
Think about the converse: does the article’s argument make less sense than the oft-held argument that someone who does not have extensive training in a specialist’s field should be more capable and more efficient than the specialist?
If there is something unusual about the patient’s complaint or findings or they are not responding to normal treatment than it is reasonable to go to a specialist. However, as much as it is popular to say otherwise, the majority of people respond to the standard treatments quite well. Oftentimes when I have a patient demand a specialist for some relatively normal disease and I send them they come back having had a lot of normal tests and procedures and the same(or equivalent) medicine to what I already had them on or recommended. Well, except that they come back on brand-name Xyzal instead of generic certrizine. So at least the pharamcy companies are happy.
One if the problems of primary care is finding doctors who want to do it. Maybe the answer is to have more specialists with easier access that will reduce the load on generalists.
A primary care doc will treat the allergies during the same visit that the patient is being seen for diabetes, hyperlipidemia, depression, and low back pain.
Have you ever seen the work-up an allergist does on a patient with hay fever, to be followed by years of immunotherapy? Very cost effective!
Peter’s argument sometimes holds water but not always. Why not? A lot of times specialists do things because other specialists do it, not because it is the right thing to do. Examples: See the post on mammography from today. I guess all those radiologists pushing mammograms missed the mark. And if you think that urologists screening for prostate ca is better than that of generalists, well, you’d better think again.
Another reason is of course pre-test probability of disease. If that is low, specialists are less cost effective, given their tendency to engage in more extensive workups and their higher baseline fees.
Yet a third reason is management of pts with several diseases. Here one generalist blows a team specialists out of the water in terms of cost-effectiveness.
Also Peter writes about precision of diagnosis. Not so fast. I can diagnose a lot things as well or almost as well as most specialists. Treatment is another issue of course.
Finally, this issue has been studied up and down, right and left. A HC system with lots a generalists and relatively fewer specialists is more cost-effective and has lower mortality rates than the other way around. It’s a settled issue.
“I can diagnose a lot things as well or almost as well as most specialists. Treatment is another issue of course.”
You seem very confident. What if you’re wrong? Are you so sure that you won’t send them to a specialist for evaluation?
Regarding specialists doing what other specialists do, there is a phrase, “Reasonable and prudent member of the profession” that should resonate.
Tom You must not be in medicine. Your faith is specialists is misplaced. Some are great, some are horrible, most are in the middle. I know it’s counter-intuitive, but it’s true. We do lots of things just as well, just as well being defined as equivalent morbidity and mortality endpoints . And it’s not me, I’m not special. Most generalists can do lots of things as well as or better than specialists, and of course much more cost-effectively. Anecdote: I once had an infectious disease fellow at the University of Washington try to tell me to treat MRSA with IV vancomycin–thousands of dollars. Of course I gave the pt oral antibiotics and she did fine. Last time I’ll consult with that guy. Remember that we too are specialists–in common problems and in the management of multiple problems in a single patient. A partial list of where we do better or just as well:: Management of hospitalized patients (most hospitalists are general internists or family docs), stable heart disease (not unstable )diabetes, hypertension, obesity, osteoarthritis (not rheumatoid arthritis though), thyroid disease, stable asthma, allegies not requiring immunotherapy, common skin disorders, acne, stable COPD, pneumonia, acute respiratory infections,acute gi disorders, most cases of laceration management, wound management, minor burns not require skin grafting, acute musculoskeletal disorders that don’t require surgery, migraine, other headaches, depression, anxiety, personality disorders, etc, etc, etc. The list goes on and on.
Where do I do poorly relative to the specialists? Epilepsy, multiple sclerosis, any disease that requires major surgery, major burns, major trauma, cancer treatment with chemo or radiotherapy, bipolar disorder. The list goes on and on.
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