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Dr Perkins, can you come see this baby? Something about it just makes me feel uncomfortable.

I walk into the exam room to evaluate the week-and-a-half-old baby that was being seen by our new nurse practitioner. The child had a late morning appointment, the mother having called at 8 because the baby “wasn’t feeding.” No fevers, nothing else out of the ordinary per mom (although the baby did up having a fast heart rate). But as soon as I walked into the room, I quickly agreed with the nurse practitioner. The child was sent to the hospital for a “septic work-up” and was indeed septic.

Dr Perkins, I just don’t feel good. I have this chest pain when I go to sleep at night. Not during the day, mind you, only at night. That’s right, it hurts right there when you mash down.Why, yes, I have been getting a little short winded when I walk the golf course but isn’t that just weight gain?

Despite the reassurance that reproducible chest wall pain brings, based on reduced exercise tolerance we went ahead and obtained an EKG. To make a long story short, 3 vessel disease.

It was quite the Monday.

Despite running a busy department, I do a lot of clinical medicine. Trained in the underserved environment where I continue to practice today, I care for all ages, do some minor procedures, deliver babies (and now the babies of the babies I delivered). As my practice has aged with me, I see a lot more older than younger folks and find myself diagnosing more dementia and less strep throat the older I and my patients get.

Being comprehensive defines my specialty along with continuity, coordination, and first contact care. We preach to our learners the importance of these attributes, we test our graduates on the comprehensiveness of their knowledge, and we criticize ourselves for allowing our scope of practice to shrink. Now there is one more piece of evidence that should make us think twice about that cushy outpatient job ($50,000 signing bonus, no call, no hospital, 15 minutes to the beach). The Graham Center has authored a very elegant study that links scope of practice with actual practice. They found that doctors who were able to do more (were more comprehensive in their approach) had Medicare patients who were less likely to be hospitalized and who had better care-seeking behavior. By better, I mean that they cost the system about 15% less.

Not measured in this study were quality and patient satisfaction. This is important. As one of the commenters points out, sometimes comprehensiveness can be misused.

[F]or some populations with higher disease burden, high comprehensiveness (or scope, as we say) may be counterproductive. PCPs that maintain “too much” comprehensiveness for patients who need more contributions by other providers may be doing so because of lack of coordination with specialists, inadequate supply of alternative providers, an inability to recognize limitations, or resistance to “letting go”. Whatever the reason, the decreasing value of expanded scope in high risk individuals is a phenomena we have seen in numerous populations.

Despite these limitations, this is important.  In the words of Kevin Grumbach (one of the smartest people I know) on NPR (one of the best sources for information I know)

the new study confirms a belief that had long been suspected, but has rarely been proven: Coordinated care, led by a family doctor who is judicious about referring patients to specialists, leads to cost savings.

“It goes from a matter of philosophical preference to actually showing that this saves money,” Grumbach says.

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National Public Radio ran an article Tuesday about a family’s struggle with a lack of affordable health care. The protagonist, Amber Cooper, was employed as an accountant in a firm and a change in insurance left her with significant ($20,000 annually) out-of-pocket expense in order for her to continue her life sustaining treatment plan. The story was one of how the family made do with that much less over several years and is now doing better thanks to another change in coverage that her employer made. Paul Fronstein, of the Employer Benefits Research Council outlines the reasoning of the company as follows:

“Employers are trying to manage those costs. They’re trying to keep those cost increases as close to inflation as possible. And they’re doing everything they can to get their workers so that they think twice about the health care that they are using,”

Ms Cooper had the misfortune of having a liver transplant when she was 10 years old. Her medical expenses are anti-rejection drugs (the lack of which will lead to acute rejection, prolonged hospitalization, and potentially a second transplant) and lab work to monitor the levels of those drugs (the lack of which would, well, see above).

So, what should Ms Cooper think twice about? Perhaps she was engaged in risky behavior prior to her transplant such as drinking or promiscuous sexual behavior and should have thought twice about that, though that is doubtful. Perhaps at the age of 10 she should have anticipated this as a potential problem and chosen an early death as preferable to a life of serfdom to the medical-industrial complex, though I suspect the decisions were those of her parents and not hers. Perhaps she should have chosen less expensive care, searching for the Dr Nick of post-transplant care, though this would likely have the same effect as not taking drugs at all (see above). What she chose to do was to pay what she could, seek out charity for some care, and defer other needed care to be able to continue to afford food and shelter for her family. All necessary but risky decisions.

Ultimately, Ms Cooper’s company selected another insurance and she is back on her medication and being monitored appropriately. This speaks to the need to provide a seamless, affordable package of benefits regardless of who is paying the bills, including individuals.

What the reporter describes mirrors what I see as a primary care physician. Patients have reduced access to less expensive, primary and ambulatory specialty care as a result of increasing deductibles, co-pays, and arbitrary denials of coverage. Those that are unfortunate enough not to lose their job and move onto Medicaid become sicker and sicker, leading to heroic hospital based rescue care (subsidized in part by the community or the federal government). Each hospitalization leaves these patient  just a little weaker and that much closer to being on disability instead of holding down a job. Unless repealed, replaced or nullified, access and quality of primary and ambulatory specialty care will improve as a result of the ACA. Some of the  improvements in care delivery are happening now and some (near universal access and standardized benefits) will take effect in 2014. It will make my job, keeping people healthy and out of the hospital, that much easier.

I ask a question of medical students in a class that I teach:

“List the biggest public health achievements of the past 10 years.”

The WalMart $4 formulary  makes it every time. WalMart claims to have saved patients over $3 billion by providing high quality, low cost generic medications to the American public. In fact, Walmart estimated that 30% of its $4 generic patients in 2007 were uninsured. I use this resource a lot for my patients and they are grateful for it.

However, based on an NPR report today, I thought I might find myself in competition with WalMart myself:

In the same week in late October that Wal-Mart said it would stop offering health insurance benefits to new part-time employees, the retailer sent out a request for partners to help it “dramatically … lower the cost of healthcare … by becoming the largest provider of primary healthcare services in the nation.”

On Tuesday, Wal-Mart spokeswoman Tara Raddohl confirmed the proposal. She declined to elaborate on specifics, calling it simply an effort to determine “strategic next steps.”

The 14-page request, which you can read here, asks firms to spell out their expertise in a wide variety of areas, including managing and monitoring patients with chronic, costly health conditions. Partners are to be selected in January.

Analysts said Wal-Mart is likely positioning itself to boost store traffic, possibly by expanding the number of its in-store medical clinics and the services they offer.

The speculation is that WalMart might even be taking it a step further:

In-store medical clinics, such as those offered by Walmart and other retailers, could also be players in another effort in the health law: encouraging collaborations of doctors and hospitals who want to win financial rewards for streamlining care and lowering costs. Such collaborations, known as “accountable care organizations,” might contract with in-store medical clinics, says Paul Howard, a senior fellow with the Manhattan Institute for Policy Research. He has studied retail clinics, some of which have recently expanded to offer services beyond simple tests and vaccinations, such as helping monitor patients with diabetes or high blood pressure.

NPR later published a semi-retraction:

Updated at 2:52 p.m. ET: Wal-Mart issued a statement Wednesday saying its request for partners to provide primary care services was “overwritten and incorrect.” The firm is “not building a national, integrated low-cost primary health care platform,” according to the statement by Dr. John Agwunobi, a senior vice president for health and wellness at the retailer).

It was fun to speculate on the effect of a true primary care presence in WalMart. According to one source “Their traffic has been declining for over two years and they’ve been losing market share.  If you get someone in the door, you can also sell them milk and a shotgun.”  I don’t know that aren’t going to  be unexpected consequences. It may not be the same in other primary care offices, but our waiting room commonly has people in it who are SICK! They are bleeding, febrile, and I suspect not very fun to be around. Do you really want to stand next to the person with influenza in Line 3? I will also add that no patient has ever ask me if I sell shotguns.

As a man, I do not feel qualified to comment on the relative merits of society paying for contraception as opposed to Viagra (although that does not stop some people). Unfortunately, the requirement for insurances to include contraception coverage in the Affordable Care Act has sparked a discussion regarding contraception that seems to be fueled more by emotion than science. I was struck by this quote from the floor of the House of Representatives (as quoted by NPR) regarding the use of contraception to prevent unwanted death and disability:

“Well, if you apply that preventative medicine universally, what you end up with is you’ve prevented a generation. Preventing babies from being born is not medicine.”

I realize that science trumping deeply held beliefs has fallen out of favor as a means of setting policy. I realize that by limiting education on human reproduction we are not stopping boys and girls from having sex as by their 19th birthday— seven in 10 teens of both sexes have had intercourse (data found here) — but we are creating a group of people who are  ill-informed regarding their own health risks. From a journal article published in 2011:

Of the 248 women who provided information for analysis, over one quarter of women could not correctly name any health risk associated with pregnancy. When shown a list of potential health risks, only 13.3% correctly identified all the health problems that increased in pregnancy. Only 49% knew that risks of venous thromboembolism (VTE), diabetes and hypertension increase in pregnancy; 30.6% did not know that VTE risk increases. Over 75% of respondents rated birth control pills as more hazardous to a woman’s health than pregnancy. The greater the women’s education, the more likely she was to believe that oral contraceptives are riskier than pregnancy.

To help folks out, below is an insert that comes with EVERY PACK of oral contraceptive pills sold in this country:



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