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The state of primary care
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A reform is a correction of abuses; a revolution is a transfer of power. – Edward G. Bulwer-Lytton (1803-1873), English politician, poet, playwright and novelist
A people that values its privileges above its principles soon loses both. – President Dwight D. Eisenhower, First Inaugural Address, Jan. 20, 1953
A recent series of perspectives on health care, medical cost control, nce improvement, and the future of primary care in The New England Journal of Medicine warrant attention.
William T. Gerson
Why such a renewed interest in the future of primary care? Not because many want to walk in our shoes — more likely because others are interested in changing our wardrobes. While an updated look is not unjustified, even warranted, the fundamental question in my mind remains as to who will have seats at the table where decisions are made as we reform health care.
I wonder if the table discussion reminds us of peace efforts in Korea or Vietnam, where combatants endlessly debate table shape, or rather a cooperative effort of stakeholders at local levels devising regional solutions. I suspect some hybrid will evolve with defined limits at a national level, allowing some degree of local innovations. However, power will likely still remain with those with the least experience with providing primary care and the most susceptibility to lobbying efforts.
At the local level
Watch your closets. Those with the power and authority are not looking at reform as a means to correct past abuse, nor even at a more needed revolution, but as a means to consolidate their own positions. Your local hospital comes to mind.
The upward pressure of increasing health care costs has finally forged a consensus that our nation cannot afford a medical future without health reform. Politics, and the courts (not necessarily different), will likely define whether this will be a reform or a revolution. Odds obviously favor reform. A revolution would require acknowledgment of the social sphere of medical costs (poverty, injustice, inequality, underemployment, etc) and that level of awareness is but a dream. Even here in Vermont, where we are actively pursuing a single-payer model, our horizons are still limited by narrow definitions of health care costs.
The articles in The NEJM discuss the change in the ethical debate over rationing of care, now that cost is openly allowed to be discussed. Rationing, although politically suicidal if spoken, becomes ethically acceptable as cost to benefit, equalization of access, and elimination of waste predominate the argument. We must, given finite resources the argument goes, explicitly ration to avoid distributive injustice. Outside of perhaps Oregon, however, no organized political union has attempted to define the spending cut-points on which treatments or services pass or fail acceptance on a prioritized list. Whether useful as a rationing tool or not, the public debate inherent in such attempts does seem to be fundamental to any such expanded effort.
Elimination of waste
Elimination of wasteful, non-beneficial interventions or actions is indeed ethically mandated. Useless tests, treatments, and even certain screening measures are harmful. We may have many years of savings just on the estimated 30% of current cost ($800 billion) going to waste; but we must agree on how to implement a model that effectively identifies, studies and eliminates non-beneficial actions and anoints effective strategies of care to move beyond the temporary benefit of waste elimination to long-term cost and quality improvement.
Today, the evidence for outcomes-based choices is often weak — but not out of reach of current comparative effectiveness research programs, if supported financially. Outcomes research and comparative efficacy studies are expensive to do well. We should strongly advocate for improved funding of the NIH. Certainly in the case of pediatrics, NIH funding of networks of care models, besides basic and clinical research, has been and continues to be fundamental to improving pediatric care.
Eliminating ineffective care is one thing, but restraining beneficial care and associated new technologies is also ethically challenged as a course of action. Health care costs will continue to reflect contributions from expensive new strategies whose cost/benefit analyses will necessarily be left for a future reckoning. I would also argue that our current funding of complementary and alternative care only contributes to waste, as it is clear that a finding of no benefit for these modalities does not translate into diminished utilization, thus continuing wasteful spending on top of the costs of studying the modalities in the first place.
Take action
As physicians, we should be engaged in these efforts and not act reflexively dismissive in the name of fidelity to the individual patient. However, we also must be vigilant and active partners. For a system to evolve where best practice truly reigns, there will need to be a clear avenue for the physician to advocate for the individual patient who requires a deviation from the current care model, based on specific knowledge of the patient, or as group physicians should not engage in the process. We need also to remember our obligation to all patients, not just the one in front of us, and if cost constraints unfairly allow access to care of some and not others, we contribute to ethical compromise. Our principles should inform our privileges.
References:
Bloche MG. N Engl J Med. 2012;366:1951-1953.
Blumenthal D. N Engl J Med. 2012;366:1953-1955.
Brody H. N Engl J Med. 2012;366:1949-1951.
Ghorob A. N Engl J Med. 2012;366:1955-1957.
www.nejm.org/search?q=perspective&asug=perspectiv