How primary care physicians can improve health and lower costs

Ok, I confess. I have contributed to the $2.3 trillion that our country spends on health care every year. As a patient I want the best possible care for my family and me. As a physician I am the gatekeeper to expensive procedures, medications, and diagnostic tests. However, by several indices including life expectancy, infant mortality rate, and satisfaction with the health care system, we are not getting our money’s worth.

As discussed ad nauseum during the health reform debate, we can point the finger at any number of parties for the high cost of care: hospitals, the pharmaceutical industry, insurance companies, and patients. I would also add to that list health care providers.

Every physician that I know makes medical decisions with the patient’s best interest in mind. But conscious or not, there are competing influences. Patients may demand a particular medication they heard about from a friend or TV commercial. A drug representative may suggest the physician prescribe their drug over a cheaper medication that works just as well. A provider may order a few extra tests not because it is supported by evidence but out of fear of being sued. A procedure may be performed more often than medically indicated because it brings revenue to the practice.

The overwhelming direction is toward more care and higher costs. As much as 30% of all health care spending is estimated to go to unnecessary care. The other problem in this situation (and in a lot of others I can think of) is that more is not always better. In fact, more care can cause harm. The overuse of antibiotics have contributed to the rise in drug resistant bacteria that now make even simple infections harder to treat. The repetitive use of x-rays and CTs increase the risk of cancer particularly in children. Painful testing and potentially harmful procedures are often performed even when the results will not change the condition’s management.

So what should health care providers do differently?

The Archives of Internal Medicine recently published a study conducted by the National Physicians Alliance on the “Top 5″ things primary care physicians can do to improve the health of their patients by reducing health care costs. Through a series of discussions, groups of pediatricians, family physicians, and internists each developed a list of five evidence based recommendations that if followed would get more value out of health care dollars. This was followed by review and feedback from 255 physicians in these specialties.

Few of the recommendations are surprising and frankly most are considered standard of care practices. Throat infections should test positive for streptococcus prior to prescribing antibiotics. Doctors shouldn’t order annual EKGs or any other cardiac screening for low-risk patients who don’t have symptoms.

Hopefully, initiatives such as these will help physicians provide both better care and serve as better stewards of our nation’s health care dollars.

Top 5 Internal Medicine

  • Lower Back Pain: Don’t do imaging for lower back pain within the first 6 weeks unless red flags are present.
  • Screening: Don’t obtain blood chemistry panels (eg, basic metabolic panel) or urinalyses for screening in healthy adults who don’t have symptoms.
  • EKGs: Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.
  • Cholesterol Lowering Drugs: Use only generic statins when initiating lipid-lowering drug therapy.
  • Bone Density: Don’t use DEXA (bone density) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.

Top 5 Pediatrics

  • Throat Infections: Don’t prescribe antibiotics for pharyngitis (sore throat) unless the patient tests positive for streptococcus (Strep throat).
  • Head Injuries: Don’t obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors.
  • Fluid in the Middle Ear: Don’t refer otitis media with effusion early in the course of the problem.
  • Cold Medications: Advise patients not to use cough and cold medications.
  • Asthma: Use inhaled corticosteroids (a steroid medication) to control asthma appropriately.

Top 5 Family Medicine

  • Lower Back Pain: Don’t do imaging for lower back pain within the first 6 weeks unless red flags are present.
  • Sinusitis: Don’t routinely prescribe antibiotics for acute mild to moderate sinusitis (inflammation of the sinuses) unless symptoms – which must include purulent (full of pus) nasal secretions AND maxillary (upper jaw bone) pain or facial or dental tenderness to percussion – last for 7 days OR symptoms worsen after initial clinical improvement.
  • EKGs: Don’t order annual EKGs or any other cardiac screening for low-risk patients without symptoms.
  • Pap smears: Don’t perform Pap tests on patients younger than 21 years or in women have had a hysterectomy for benign disease.
  • Bone scans: Don’t use DEXA (bone density) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.

[In full disclosure, I serve on the Board of Directors of the National Physicians Alliance and am a member of the pediatrics working group for this study.]

Ricky Y. Choi is a pediatrician who blogs at
SFGate and reprinted with the author’s permission.

 

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  • http://www.drdarrellwhite.com drdarrellwhite

    In order to arrive at your conclusions about the rationale for your suggestions it is necessary for your premises to be valid.

    1) Life expectancy. Control for accidental death/homicide in young men and the numbers are dramatically different. Look at life expectancy at age 50 and the numbers are dramatically different.

    2) Use the definition of live birth elsewhere in the world and the numbers are dramatically different.

    3) Look at “satisfaction” with the healthcare system among people who are insured, either privately or through mediCARE, and the numbers are dramatically different.

    This is not to say that what is being proposed is without merit, or that it would not work. But what do you think is the level of satisfaction ‘enjoyed’ by the patient with sinusitis whose treatment is held as you propose, who is allowed to be in pain for 7 days? Withhold referrals to specialists? In many cases that works fine (perhaps the ear example is one), but in others there is competing data to show that a prompt referral of a common problem to a specialist will result in a quicker resolution of a problem with less medication and fewer visits (eg. red eye).

    Even at that I would find it very easy to get on board as a specialist and support the entire proposal if this type of framework, created by physicians and based on sound research, could be implemented and evaluated without external (read political or bureaucratic) interference. One only needs to look at the willful and shameful disregard of a 2000 NEJM article that shows Pre-Admission Testing for cataract surgery to be a waste of money and patients’ time–no medical banefit– to realize that the power rests not in the hands of physicians but in those of nameless, faceless functionaries who decide how, and why, it “should be” done, and the hands of others (read hospitals) who profit.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    That was a thought provoking article in the Archives and an equally thought provoking post by Dr Choi. Meeting in small groups either as a hospital medical staff or county medical society and discussing these issues makes sense and allows for regional differences. If you can come to a consensus you can then begin the community wide education process so that you can convince the public that what is appropriate and works is not necessarily less or rationing. It will take education and marketing to convince the profession and the public

  • Diora

    # Cholesterol Lowering Drugs: Use only generic statins when initiating lipid-lowering drug therapy.
    # Bone Density: Don’t use DEXA (bone density) screening for osteoporosis in women under age 65 years or men under 70 years with no risk factors.

    How about don’t overprescribe preventive drugs to people with low absolute risk? Or if you wish, how about explain the risk/benefit ratio of preventive drugs in terms of absolute risk or NNT instead of meaningless relative risk numbers?

  • Mindy

    Two more suggestions for the list:

    1) Stop over-prescribing anti-depressants.

    2) Any person taking a blood pressure reading needs to learn how to do it right.

  • http://www.ConciergeMedicineToday.com ConciergeMD

    Thinking outside the box, another consideration for physicians to help save costs, reduce the amount of prescriptions patients are taking, reduce hospitalizations, spend more time with their patients, etc., is concierge medical care.

    Breaking it down by numbers and data and not simply talking in generic terms about the savings, I’ll present two cost saving features of concierge medicine. 1) Prescription Compliance/Reliance among “concierge” patients vs. “non-concierge” patients. and 2) Hospitalizations.

    Prescription Compliance/Reliance Among Concierge Medical Care Patients

    Surveys conducted over the past year (Jan 2010 to present) among concierge physicians by http://www.ConciergeMedicineToday.com indicate that ‘the most common types of phone calls concierge physicians receive from their patients were prescription drug renewal requests. These accounted for 35% of all calls while the other most common being Cold/Flu Symptoms (20%) and Back pain 15%.

    When concierge physicians were asked ‘Do you see a difference in how well concierge patients follow through and/or comply with taking prescription medications, as opposed to patients you’ve treated in trad. practice?’ the following results were found:

    67% – of respondents polled indicated that Yes! A Significant Difference;
    28% – Some, but not a big difference; and
    6% – No difference at all.
    When these same concierge doctors were asked ‘If you’ve noticed your concierge patients do better when taking their Rx meds, what do you think accounts for this change?’ we found the following results:

    • 38% – I follow up personally to ask about medication use and side effects, and to encourage compliance.
    • 28% – I spend more time explaining the importance of medication compliance.
    • 28% – The patient has more confidence in my recommendations and will follow them.
    • 7% – Other.

    Concierge physicians may indeed take a more conservative approach to prescribing multiple medications, but their high level of attention to patient care may at the same time promote greater medication compliance. Is one to presume that patients who have a concierge physician develop closer relationships with their doctors and therefore respond more positively to medical advice? That could be the case. The hallmark of concierge medical care is the doctor’s more personalized approach to treating individual patients, which in turn allows more time to research appropriate treatment alternatives and spend more time counseling and following up with patients. As the drug company executive noted, one outcome of concierge care is fewer prescriptions. However, the high proportion of prescription requests suggests concierge medicine patients may also exhibit higher levels of medication compliance

    Hospitalization Data Among Concierge Medical Patients.
    (Source: http://conciergemedicinetoday.com/hosp.html)

    MDVIP’s avoidable hospital rates average 16.6 admissions per 1,000 people. In standard insurance plans with comparable patient populations, the rate is 27.5 admits per 1,000. MDVIP’s hospital discharge rate in 2007 was roughly 105 per 1,000 members, versus 199 per 1000 members in standard insurance plans. Reports show that MDVIP is already eliminating over 9,000 hospitalizations per year, saving roughly $79 million in total health care expenditures.

    NOTE: I am not a physician or a representative of MDVIP. I am simply a believer in cost-effective ways to help patients save cost and help physicians do the same.

    • http://www.ConciergeMedicineToday.com ConciergeMD

      Good questions. Sorry, I jumped ahead.

      As a definition, concierge Medicine refers to those primary care and family practice physicians who have chosen to provide healthcare services in a more convenient, accessible and cost efficient manner to their patients. These physicians charge patients a membership fee ranging from $600 to $1,800/year and higher. In exchange for this fee, concierge practices generally include 24/7 access to a personal physicians’ cell phone, same-day appointments with no waiting, personal coordination of care with specialists, personal follow up when admitted to a hospital or ER, house calls, and more. Each patient should check with their physician to find out what services are included in their individual membership. (Source: http://conciergemedicinetoday.com/services.html)

      While a typical physician can carry a patient load of 2,500+ patients, a concierge physician generally limits their practice to between 300-600 patients or more. Concierge medicine is also referred to as: membership medicine; boutique medicine; retainer-based medicine; concierge health care; cash only practice; direct care; and direct practice medicine. While all concierge medicine practices share similarities, they vary widely in their structure, payment requirements, and form of operation. In particular, they differ in the level of service provided and the amount of the fee charged.

      You are not alone when you ask what happens if the scope of care goes beyond the concierge doctors treatment. Patients are encouraged to continue to keep some form of health insurance for catastrophic care coverage. This would include hospitalizations, ER visits, cancer treatment, surgeries, etc.

      It’s also important to understand that about 85% of the average persons care can be handled by a PCP or family doctor, according to most PCPs I talk to — of course there are always special cases that see specialist physicians more than their PCP. Knowing this, any concierge patient is encouraged to combine a high-deductible health plan policy with a concierge medical program. Thereby, empowering people and families to make better decisions about their health care. In turn, they receive more comprehensive medical care and then the savings happen and stronger relationships occur between the physician and their patients.

      I recently read a story in The NY Times that supports this belief. The paper reports that the state of Indiana has a high-deductible plan and another that’s a traditional HMO. People in the high-deductible plan spend thousands less than those in the HMO.

      “The average expense in 2009 for patients on one of these [high-deductible] plans was $6,393,” the paper writes, “compared with $8,570 for patients enrolled in a more traditional health maintenance organization plan.”

      It’s also a little known fact that nearly 60% of concierge medical programs across the U.S. cost an individual less than $135 per month. (Source: ConciergeMedicineToday.com, December 2010).

      Some programs cost as little as $10 per month for children. A practice in Wichita, KS offers flat monthly fees ranging from $10 per month for kids and $50 ,$75 or even $100 per month for adults based upon age. Members of that concierge medical practice receive unlimited access to the doctor at their home, work or the doctor’s office along with unlimited “technology visits” like cell phone, web cam, email and texting. Furthermore, many concierge physicians offer access to wholesale pricing on prescriptions, lab tests, imaging services and medical supplies for pennies on the dollar.

      Here’s the current downside in concierge medicine: We’ve recently been studying the demand for concierge, direct care, cash only and retainer-based medical models by consumers. We’re finding that the number of patients who are seeking concierge medical care is far greater than the actual number of primary care and family practice doctors available to serve them. It’s extremely difficult to find a physician for those seeking concierge physician services in very rural areas like Idaho, North and South Dakota, Louisiana, Mississippi and others. Often times, we have found that there are less than half-a-dozen practitioners to serve an entire state.

      But, there are currently four states that have a huge lead in the amount of active concierge physicians in practice and consumers seeking their care. Florida, California, Pennsylvania and Virginia each have a significant number of people (most over age 50) seeking out concierge doctors and there is, fortunately, a sizeable number of concierge physicians to serve them.

      • http://www.ConciergeMedicineToday.com ConciergeMD

        @ tony – Good comments. You might find this interesting. I recently submitted data to a prominent financial publication stating that: ‘Utilizing a blended rate based upon national averages for current fees charged for concierge medical care, an estimated 9,285,714,286 people could be provided concierge medical care with the 13 trillion dollar debt. Carrying this out 928,571,429 people could be provided this care for 10 years. These figures are based upon information obtained through average pricing surveys conducted from 2009-2010 by The Concierge Medicine Research Collective.’ (Source: http://www.ConciergeMedicineToday.com/recession.html)

        While I’m not stating that concierge medical care is a cure-all, it’s absolutely a viable alternative for patient and physicians to save dollars each year. However, I do believe, as do others — it should be added to the recipe of solutions for the future of healthcare delivery and more data is needed to evaluate it’s true cost savings features. For now, the data looks encouraging.

        In the words of a physician I recently spoke to about this topic, she agreed ‘we no longer need doctors who have to look at a chart to know our name.’ I think we can all agree about that.

  • Michael Permenter

    A high deductable insurance plan ( as opposed to high priced PPO plans), and a concierge physician. Better for patients and drs. Not good for “so called” concultants who want you to believe they can help you manage the chaos we have seen since 1965, and will get worse as the current administration pushes us into Socialized Medicine.

  • http://www.ConciergeMedicineToday.com ConciergeMD

    Good point. Thanks for listening…:) Have a great week!

  • Dorothy Green

    I learned a lot in this discussion about some of the clever and very practical ways of improving American health care. It seems, even in light of rhetoric to stop it all and go back to the drawing board (I don’t think one even exists now), progress is being made.

    Tony – it seems that eventually fee-for-service will go by the wayside – the losers in this battle will fight to keep it, just as any other Corp or person (one in the same in the US) will fight public health and reasonable healthcare reform efforts to protect their profits. Examples are pervasive selling of pharmaceuticals and unhealhy food. Keep up the fight!

    With regard to the original post – I agree with it all. Two personal comments:

    Sinnisitis – terrible stuff, experienced it myself. After weeks
    of OTC antihistamines, on and off – i went to doc (do not want to use any more than necessary). My secretions were ugly but lessening – no fever. No, to her credit, she did not order an antibiotic but gave me allergy info. Friends had same symptoms but were given antibiotics – stopped for a bit but came back. Then I read an article that even if secretions are ugly, antibiotics are not indicated – fever was the definitive factor.

    DXEA – mid 1900s – synthetic HRT known to slow bone loss of menopause which can be a 30% early on (a NEJM article). I wanted them. PCP refused. I changed Docs. I got some late in the game. Then found out risks of synthetics (this was 1997). Tried what was available in bioidentical and took those.

    Early 2000s – Bisphosphonates hit the market. PCP – “we never did bone scans before because we had nothing to treat osteoporosis” – mine showed osteopenia – asymptomatic. I was started on drugs (not 65). In few years read how they worked, stopped taking them (way before fx reports) and started taking all the bone building supplements de jour, have recently added vitamin K2.

    Moved – new PCP refuses to reorder bio HRT – all are bad. I didn’t fight it – can’t afford the new age stuff. Ordered DXEA because I am of age -why? I am not going to take Bisphos. Thinks I am silly to not have this expensive scan – “you don’t have to pay for it, it is gold standard” . I told her I passed ultrasound at healthfair with bones of 30 yr old x 2 yrs. I researched ultrasound – I know it shows osteopenia and osteoporosis (friend had same test and hers showed what she knew from DXEA) as, at least in a lot I read, compared favorly with DXEA).

    Points in my story –

    1. New info is always coming out and changing – there are lags in info about both the good and the bad.

    2. People must take responsibility for their bodies and minds.

    3. Physicians need to help us all (including themselves) from being caught in the “Big person” influence trap.

    4. Everyone should know what guidelines, “red flags” are and mostly that the real “gold standards” of PC care are a healthy diet, exercise and tincture of time. There is no “magic pill”.

    There is much education out there for the taking without individual physicians doing it one on one at high cost. Perhaps physicians should review the TV shows, internet, family home care books and collectively give a stamp of approval for those consistently useful and refer to them who do not want to go google searches.

  • WFCote

    Here’s my two cents on how to save our country a bundle on health care costs:
    1. Reform our med schools, especially in the area of nutritional training. The USDA found that approximately half of the population regularly takes nutritional supplements, but most doctors have little to no training or experience in their benefits and/or risks. Plus, many prescription drugs induce nutrient deficiencies that are often at the root of the concomitant side effects (think CoQ10 depletion with statins).
    2. Screen for autoimmune disorders. There’s an epidemic of them in our population, but few doctors have the training to properly recognize or test for them. My mother suffered for decades with debilitating inflammation. She finally gave up on her rhemutologist and sought ought a specialist in fibromyalgia. After conducting a thorough battery of tests that went beyond the typical blood test and urinalysis (a stool test and genetic test), he found she had parasites and gluten intolerance. She immediately lost about 20 lbs and has a new lease on life. (Think how much money she would have cost her insurance plan if she had kept on following the advice of her GP and rheumotologist.)
    3. Be open to alternative treatments. There is a lot of quality, peer-reviewed research being conducted and published in this area, (e.g., Nat. Center for Complementary and Alternative Medicine), but so few doctors avail themselves of it. When my neurologist recently referred me to an Advanced Orthogonal chiropractor I about fell off the examining table. She was open to this approach because she had seen first-hand the amazing results with her patients. Plus she was up on the research regarding this pioneering approach. (It worked great for my chronic sleep disorder, BTW).
    4. Stop relying so much on standard blood tests. Have you ever wondered why the vast majority of your patients who are clearly experiencing medical issues have blood tests that come back perfectly normal? There’s something that doesn’t add up here…
    5. Use the Internet – your patients are. The vast amount of research available to the general public these days is astounding. Your patients may not have an MD, but they can use Google. Be open to the research they find; it doesn’t make you less of a doctor when you consider the findings of someone without an M.D. – it makes you a better provider by admitting you can’t keep up with it all.

  • Dorothy Green

    “I find it very difficult to discuss any sort of “designer health care” when so many Americans never even get the chance to see a doctor.” by Tony.

    Then don’t.

    The stas you gave are shameful for the richest country in the world. It has bothered me over 25 yrs but my message and votes have the same basic message albeit fine tuned over the years. If healthcare reform can continue as planned then the stats Tony quoted should start changing.

    It would be terrific if the bill could have made healthcare for all possible “right now”. But it didn’t and nothing each one of us say in this blog individually or collectively will change those stats overnight. If all our individual ideas, messages, references about all the issues continues, and better, if there was some way to consolidate them and publish more extensively perhaps they will fall on responsible ears.

    Each of these blogs has some importance to someone in healthcare. That’s why I keep talking about my ideas, responding to others, reading and listening.

    It is a good place to talk about healtcare. Thank you KevinMD.

  • Leo Holm MD

    What are the “real solutions” or “serious changes”?