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Primary Errors

Reducing access to medical specialists will worsen American health care.

12:00 AM, Sep 9, 2009 • By STANLEY GOLDFARB
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Primary care medicine:
An empty promise in health care reform?

There is an article of faith among proponents of health care reform that expanding the primary care workforce, particularly at the expense of medical and surgical specialists, is a critical component of "bending the cost curve" and enhancing access to care. This approach is favored in several models of health care delivery, particularly using the concept of a "gatekeeper" physician who follows guidelines of care to prevent over- utilization of expensive care by specialists. Increased training of and reliance on primary care physicians is a stated goal of various health care proposals and has been encouraged in the past through specific funding mechanisms by the government. It has been one of the major sources of frustration with the managed care paradigm of control of utilization of medical services.

One optimistic view of how this gatekeeper model would work has the general practitioner with an orderly and happy group of patients waiting at the "gate" to find out whether they need anything more from the health care system and then gaining appropriate and easy access to advanced care when that test or procedure is indicated. Another view, perhaps a little more clear-eyed, has the primary care physician having a default position of avoiding any expensive treatment or test provided by specialists unless there is overwhelming evidence that the procedure or test will be highly likely to be effective, not just possibly effective. Which one is accurate? Are there data on the effectiveness of primary care physicians compared to specialists in the treatment of a variety of diseases? Is there not an intuitive problem with assuming a "generalist" can be as knowledgeable and as efficient and effective as a well-trained specialist given the ongoing explosion in medical knowledge and technical capabilities?

At one extreme of the medical spectrum, the case of Senator Edward Kennedy's tragic illness illustrates the dilemma posed by a health care system with enormously expensive therapies of often uncertain benefit but also offering great hope to patients with serious illnesses. After the initial diagnosis of the cause of his seizure at one of America's great hospitals in Boston, the senator and his family opted for further neurosurgical care at another of America's great hospitals in Durham, N.C. He then returned to Boston to receive chemotherapy and highly advanced radiation therapy. After what was assuredly an enormous cost, he died with his family at his side after about one year. Was all this proper and necessary? Did his need for hope and optimism about his illness outweigh the expense and effort of a treatment program that had little if any chance of a substantial prolongation of his life? Those who argue for major cost constraints on aggressive, high tech care will argue this example illustrates the need for a more rational and guideline-based care that does not opt for high cost but low-probability-of-success forms of care. Others would argue that the opportunity to receive innovative and advanced care should be the cornerstone of the American system. Clearly the senator and his family made their choice. No doubt it was based on the completely understandable impulse to seek out the best for ourselves and our families.

Yet, those who propose to use his career and his commitment to a type of health care reform that will count age and quality of life as criteria for the use of health care dollars clearly are in an ethical quandary if guideline-based care under the auspices of a gate-keeping generalist physician underlies any proposed plans--no guidelines will include required travel to the great academic medical centers of America as part of the protocol. No one disputes that under any proposed system, desperately ill patients will have access to specialty care. The question is whether that care will maintain the current high standards of advanced technology and innovative approaches to treatment if it is consistently underfunded or even implicitly discouraged.