By George H. Rice, MD (retired)
On physician reimbursement, I think all physicians should be on salary. The salaries could be based on local factors such as the Rockwood Clinic or Group Health, statewide clinics such as the Everett Clinic and national clinics such as Kaiser, Mayo, etc. My friends in those settings seem to be happy with their salaries. I think fee for service is a bit of a joke anyway, the insurance companies are going to pay you their set fee no matter what you charge. Also, setting a salary would do away with unnecessary visits and extra tests.
Electronic records are a must and record banks need to be organized where all of a patient’s information is collected and can be easily tapped into by providers at any time. In other words the medical data on an individual is obtainable almost immediately. All provider visits are recorded, as are pharmaceuticals, lab tests, hospital visits, x-rays, CAT scan, MRIs, etc. The biggest hurdle is communication between the disparate entities and the ability o f a provider to tap into the system when approved by the patient. A wonderful example of how the system would work is the Cancer Northwest network, where no matter what office you visit, they have all your current information readily available. Patients should also be allowed to tap into the record bank so they can be active participants in their own care and can read results or know what tests they have had or vaccinations they have received and when.
The way we provide care needs changing. I think it should be divided by age such as birth to 18, 18 to 65 and 65 to death. The providers of care in those settings would be nurse practitioners/physicians assistants. The initial providers would receive backup by physicians in their respective fields, say pediatricians for birth to 18, internists and gynecologists for 18 to 65 and gerontologists for 65 and older. In addition other specialties would be available for consultations and some special cases such as obstetrics, cancer, heart care, etc. would have independent practices for that special treatment. You notice I have not included family practitioners. I think that is a bit of a misnomer. They should be incorporated into the mix of pediatricians, internists or gerontologists. I think, in today’s advanced medical care it would be extremely hard to be a “jack of all trades.” Many family physicians do not have hospital privileges and do not do obstetrics or surgery today.
As an adjunct, I would add that the medical home would fit into the above setting nicely with four to six nurse practitioners/physician assistants in the home with one or two physician backups. Also, it would work in the rural setting with the home being in the local town and the possibility of home visits a reality.
I think this would meet the need of the baby boomer population that is looming and also would be cheaper way to provide care for all our citizens. I realize we need more gerontologists and that should be the focus of our “new medical school.”
I feel a need to respond to Dr. Rice’s opinion about the future of medical care in the last issue of The Message. I don’t feel a need to
ReplyDeleterespond to the controversial proposal that all physicians should be on salary though I imagine some of my colleagues might. Last year, I had
the opportunity to work with George on a presentation regarding the future of medicine and found him to be thoughtful, attentive to his
audience, and clearly invested in healthcare for patients.
In spite of that, I think his lack of appreciation for Family Medicine as a Specialty is ill informed and worthy of discussion. Dr. Rice writes, They (family physicians) should be incorporated into the mix of pediatricians, internists or gerontologists. I think, in today’s
advanced medical care it would be extremely hard to be a “jack of all trades.” Many family physicians do not have hospital privileges
and do not do obstetrics or surgery today.
While I appreciate the idea that some people will be better served or prefer being seen by a Pediatrician, an Internist, or a Geriatrician,
I believe it ill conceived to suggest that this should be a cornerstone of good medical care. There are certainly different issues which we face as we age but I believe to base a healthcare system on this would be misguided. I think it a mistake to de-value the contribution
family physicians (who are trained across the age spectrum) offer to the health of this nation.
I do not think of myself or my family medicine colleagues to be “jack(s) of all trades.” Rather, I consider family physicians to be the
providers of choice for the majority of health issues for the majority of the population, providing continuity and collaborating with our
valued specialty colleagues. Furthermore, I suggest that Dr. Rice is correct in stating that this is inherently “extremely hard” and (I would
add it takes an excellent physician to do this job well).
Additionally, the impact Family Medicine Physicians make in the rural arena is profound. If we were to remove Family Physicians from Washington State, approximately 2/3 of our counties would be or become Health Professional Shortage Areas (HPSAs). See the following link from the Graham Center for an interactive
map. http://www.graham-center.org/online/graham/home/toolsresources/
maps/maps/hpsamaps.html. I am certain that Dr. Rice was not suggesting this transition away from Family Physicians occur overnight; but rural America is not adequately populated by
Pediatricians at this time and outpatient General Internists are a valued, and rare entity in both urban and rural arenas. There are
reasons this evolution has occurred and a re-working of the health care system might be able to address this issue.
Finally, I must add a personal note. I look forward to my family physician, Jim Bingham, MD continuing to provide excellent care for me and my family. I would be disillusioned if my children “graduated” from his care and had to seek another physician when they turn 19 or I had to transition when I turn 65. Dr. Bingham has a contextual relationship with my children, my wife and me. It would be a shame to “age out” of that relationship. When I become a geriatric patient (I am not sure that is a chronological age phenomenon), I look forward to continued excellent care by Dr. Bingham, and if need be, a referral to one of my highly valued specialty colleagues for whatever needs I have developed.