Fixing Primary Care

An impressive survey published recently in the Archives of Internal Medicine revealed the startling statistic that 42 percent of American primary-care community physicians believe that their patients receive too much medical care, and acknowledge that they over-treat their patients, mostly for non-clinical, non-compassionate reasons. Seventy-six percent of these physicians attributed this excess of medical expenditure to malpractice concerns (aka defensive medicine).

Excess unnecessary care means excess expenditures, which leads to the necessity of healthcare reform because of rising costs. And all of this excess care occurs in the face of the fact that Americans are getting sicker, more obese, less healthy, and more depressed.

So when all of the ruckus was occurring with regards to healthcare reform last year, I was among those who opined that primary care was the problem and needed to be fixed and reformed. There is a well-documented shortage of doctors who are overworked, underpaid, undervalued, and frankly untrained in essential aspects of healthy living such as nutrition and lifestyle. The healthcare debate suggested ideas about pay-for-performance to motivate physicians (which is turning out to be less effective than previously thought) and the patient-centered medical home (which is turning out to be a front for the advent for massively bureaucratic accountability care organizations), while no energy was devoted to the essential aspects of how to get Americans healthier.

As the Archives study indicates, primary care needs to be reformed, and malpractice law needs to be reformed (tort reform). I have no doubt that President Obama’s team is aware that tort reform is imperative. Here’s what I think needs to be done to reform primary care:

1. Assemble an army of primary-care physicians (hire foreigners - there are thousands of excellent brainy Indian physicians aching for a visa to enter this country and practice medicine in the places American medical school graduates refuse to go.

2. Assemble an army of nurse practitioners and physician assistants. Some of the most talented people I know in healthcare are NPs or PAs. Assign a team of such mid-levels to each primary-care provider and give each provider access to a fully-equipped, certified EHR. Have 24-hour tech support for the EHR, and hire hundreds of software engineers available to help the care providers.

3. Make exercise the cornerstone of primary care. Patients should be hoisted onto exercise bicycles within minutes of entering a clinic. Exercise capacity, the presence of surreptitious angina, and education level can be determined within 10 minutes. Patients will be given supervised exercise protocols with slow up-titrations of intensity, practiced daily.

4. Make food/nutrition the other cornerstone of primary care. Direct recipes with information about where to procure inexpensive ingredients (Wal-Mart/Costco, local grocery markets) will be given to patients.

5. Smoking cessation programs will be instituted immediately, and aggressively managed by mid-levels.

6. Institute heavy financial fines for those who continue to smoke and who are non-adherent to food and exercise regimens.

If this is done for six months, not only will primary-care physicians realize patients are taking more responsibility for their care, but also there will be an overall improvement in health, less atherosclerosis-induced fatal events (heart attack, stroke), and less medical expenditures.

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