A view of health care from the primary care physician

An interesting article from the policy journal Health Affairs. They look at issues relating to Primary Care Physicians in seven countries - notably they leave out the Nordic countries that provide better care through higher taxes. I don't know if I have a point to all of this, but I just wanted to show you some of the differences in quality of care and type of care that we are left with here in the US becauses of our current fragemented system. Quotes and thoughts after the break.

First, a definition. Capitation- A fixed prepayment, per patient covered, to a healthcare provider to deliver medical services to a particular group of patients.

Countries also differ in the way primary care doctors are paid and in insurance coverage. The United Kingdom pays for primary care on a capitation basis and has new incentives for quality improvement.4 Recently, the Netherlands switched from predominantly capitation payments to a mix of capitation and fees.5 All of the other countries pay primarily on a fee-for-service basis, although New Zealand, through its creation of Primary Health Organizations, has moved toward capitation. The United Kingdom provides the most comprehensive coverage with little or no patient cost sharing.Canada covers physician visits in full, but medication coverage varies by province . Australia, the Netherlands, New Zealand, and Germany include varying degrees of cost sharing. New Zealand, however, is reducing or eliminating patient fees for primary care, particularly for vulnerable populations. The United States stands alone with a high share of the population that is uninsured; when people are insured, they often face high cost sharing, including deductibles, for primary care.

The employer-based system did not always work this way, my Dad never used to pay premiums or deductibles or copays or coinsurance through Blue Cross/Blue Shield. But, that was 30 years ago. If only people woke up to how much extra they pay just to employ the health insurance industry.

Another brief definition: EMR - Electronic Medical Records, These include practice- and systemwide information systems capable of following patients across sites of care, supporting disease management, preventing duplication and medication errors, and improving clinical quality; organizing practices to assure timely access; and payments that support prevention/care management and provide incentives to improve.

The vast majority of physicians in Australia, United Kingdom, and New Zealand reported seven or more of fourteen specified functions, as did 59 percent of Dutch doctors (Exhibit 2Go). Canadian and U.S. information systems lag well behind those of the other countries: A majority of physicians there reported two or fewer functions.

Which means, they don't have your records, fill out these forms, again, take these tests, again, here is a prescription for a drug you already have a prescription for or a prescription that cross-reacts with this drug, hope you don't die, and the doctor will be 2 hours late to your appointment because of double-booking.

Treatment of Chronically Ill Patients and Use of Teams. I'll let you click on this link, which should open up a table. It's pretty straight forward - the US is less prepared to take on chronically ill patients, mentally ill patients, or to work as a multidisciplinary team.

Access to Primary Care and Physician Hours.

After-hours coverage arrangements vary remarkably. Three of five U.S. and half of Canadian doctors said that they have no after-hours arrangements. In contrast, at least three-quarters of physicians in the other countries, including nearly all Dutch doctors, reported having these arrangements. Notably, in 2004 and 2005 patient surveys, patients in both Canada and the United States reported difficulty getting care after hours and the highest use of the emergency room (ER) for care that could have been provided by a regular doctor if available.16

This is a huge problem, especially for parents. Every time I have ended up in an emergency room, for whatever reason, it has been packed with sick kids. Duke has an entire ER dedicated to kids, so they are whooshed in with no waiting. When I think about care for kids, a peds clinic, I think about the group we used in South Florida. They had four or five offices and one of them was open and fully-staffed 24 HOURS A DAY. I cannot tell you what a relief that was when, at 7pm, we decided our son needed to be seen for what turned out to be a double ear infection. We called the hotline, were told which clinic was open, drove 20 minutes, and were seen within 15 minutes. A frickin' miracle compared to Duke or UNC.
Finally, I'm going to end with the conclusion of this article and just let the author's lay it out for you.

U.S. exceptionalism. The United States outspends the other countries: Total per capita costs in 2003 came to $5,635, compared with $2,876 in Australia, $3,003 in Canada, $2,996 in Germany, $2,976 in the Netherlands, $1,886 in New Zealand, and $2,231 in the United Kingdom.37 Yet U.S. primary care physician practices are more limited than the leading countries in information capacity, provide less patient access outside of "normal" work hours, and are among the least likely to use teams or to receive financial rewards for quality. U.S. physician responses further indicate little capacity to generate information to compare or assess performance from either internal or external sources. Together these responses add up to a U.S. primary care practice profile with less capacity to ensure accessible, high-quality, or patient-centered primary care.

International comparative studies indicate that these deficits matter. The United States is often not a leader on clinical outcomes and ranks low among industrialized countries for mortality from diseases that are amenable to medical care, despite much higher spending.38 In the 2005 survey of patients, the United States often ranked last or tied for last on safety, access, and care efficiency.39

As the United States confronts how to redesign incentives to improve access, quality, and efficiency amid a more fragmented payer system, it has an opportunity to learn from the diverse approaches in countries that are implementing systemwide initiatives. From an international perspective, the survey findings underscore the need for new national policies. Cohesive, broad-based policy changes in the United States could lead to improved absolute and relative performance.

NC Defend Health Care - fighting for Universal Health Care in North Carolina.

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