ACP: A Senate intern turned internist seeks solutions to better patient care

ACP: A Senate intern turned internist seeks solutions to better patient careA guest column by the American College of Physicians, exclusive to

In early June I participated in ACP Services 2012 Leadership Day on Capitol Hill in Washington, D.C.  I sincerely believe that we have an obligation to share our experiences with elected representatives. Internists through ACP have been doing this for years and have raised awareness of the high fiscal and personal costs of our uninsured. We have stressed the need for more primary care and a more rational payment system.

Over the years I have made many Hill visits and have gotten to know Tennessee legislators and their staff well. Some faces change each year and the climate certainly is different but I continue to be impressed with the intelligence, hard work and dedication of those we visit. Even when we disagree on an issue, I generally feel that their intentions are good.

My visits with Representative Jim Cooper, who represents Andrew Jackson’s old district in the U.S. House, are always enjoyable. In preparation this year I replayed an interview he did with others last year on PBS about the dysfunctional nature of government these days. Rep. Cooper gave us a sobering assessment of the difficult path ahead that had the Tennessee internists yearning for antidepressants. It is clear that we cannot expect a “fix” from government in the current political climate.

After this year’s congressional meetings I had an additional realization. I could easily have ended up very frustrated as a player in the inner workings of a broken government. In 1971 I interned in the U.S. Senate and later was a political science major in college. Some might say I left a broken political system and went home to a broken health care system but I feel privileged being able to help one patient at a time.

The day after my Washington visit I saw a patient for an urgent (but non-emergent) issue. She had moved to another city but her new doctor was very hard to see. I saw another patient who could not afford the concierge practice that her doctor of many years had joined. I came in early to see a relatively new patient to allow her to get on her way to the first of the two jobs she needs to make ends meet.

Each day as a doctor I get immediate gratification every time I am able to help a patient. I get longer term satisfaction trying to improve our practice in these challenging times. Hopefully we can all do our part to change the delivery system so it is easier and better for the next generation of patients and doctors.

I‘ve had interesting conversations with patients after the Supreme Court decision on the Affordable Care Act.  In some cases with those who are uninsured it involves the uncertainty of the prices available through the insurance exchanges or whether Tennessee will agree to expanded Medicaid coverage. In all cases I try to emphasize that there is no one simple answer to our health care challenges.

The particular solutions to these challenges will certainly vary in different parts of the country but I feel that many elements will likely be shared. We are perhaps a bit ahead in Fayetteville, Tennessee because so many of the doctors we produce choose to return home to practice. We are using that head start to try to move toward a team based practice that can evolve into a true patient-centered medical home.

We need to try to put the pieces together in our community and explain our needs to elected representatives. Right now I’m not expecting too much new from government except not to pull the rug out with massive Medicare cuts. Over time I hope we can coax Medicare toward some of the innovative approaches being tried at the local level.

Former Senator Bill Frist recently talked about how much various influencing factors play into overall health. He cited genetics at 20 percent or more, socioeconomic status 15 percent, environment 5 percent — but felt the biggest power may lie in combining health-care services at 15 percent and behavior at 40 percent.

ACP at the national level is trying to make a difference with its High Value, Cost-Conscious Care initiative. We need to know the best options for our patients. That is a great start but needs to be supplemented with healthier lifestyles.

I would love to learn more about local efforts to improve lifestyles – either in the medical office or in the community, and hopefully both. If we can find techniques that have worked other places I would love to recruit friends and colleagues to help make our community healthier. If you have examples of things that have worked in other places, please share them.

No one thing is going to fix American health care, but if we all work together we likely will find that we have many common goals that everyone agrees will help our patients and communities. Then we can hash out the delivery and payment system but with a better and healthier footing.

Fred Ralston practices internal medicine in Fayetteville, Tennessee, and is a Past President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • Jeffrey Mendenhall

    Dr. Ralston — I am very impressed by your passion for “high quality, cost-conscious care”, but most of all by your joy beyond even what you referred to as “gratification” in helping your patients. I am a BSN-prepared nurse, with advanced certifications, now disabled by chronic pain secondary to a battered lower back and severe arthritis: so I now write evidence-based CME items for a peer- reviewed journal in Family Medicine. I have been particularly impressed by the ACP’s leadership in promoting quality, evidence-based care in your primary care specialty. I live in Salt Lake City, an area identified by the Dartmouth Atlas, among others as one of those sadly rare pockets across our country with high quality, lower cost health care. One of many reasons lies in very advanced EHR and health informatics, jointly developed and shared by the three major provider systems in our area: the Univ of Utah Health Care system, Intermountain Health Care, and the SLC VA’s outpatient clinics — especially their outpatient geriatric clinic. This is far beyond most dreams of “meaningful use.”
    But as a society we are crippled morally as well as in the literal sense by our obscenely high cost and poor outcome non-system of health care. We have several systems of reimbursement for care provided by institutions, physicians and other providers, and of course, the 800 TON gorrilla in the chambers of Congress, and therefore our wallets — the pharmaceutical industry.
    Most of my career I worked in hospice, primarily as a supervisor, then manager and clinical director, then program director. My leadership roles merely give me a great deal of experience managing the limited resource of per diem, per capita payments from Medicare, Medicaid, and various insurance companies. I practiced in CA and CT, and research performed by Dr. Betty Farrell and her team at the City of Hope National Medical Center showed what I already knew first hand: timely (“upstream”) referrals to hospice care were far more frequent in “markets” with substantial, mature managed care insurance models. CA had and has many; CT had and still has relatively few. Those terrible “brink of death” hospice referrals were and are far more common in … CT. As we still struggle for broader acceptance and commitment to evidence- based practice (a JAMA editorial first called for this in 1992!), including the proven strategy of applying targeted algorithms, we must also advocate for a true health CARE system.

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