Too Many Blood Pressure Pills—Here’s A Time When Treatments Go Too Far

You’re in the hospital with an acute illness. Perhaps your gallbladder is acting up, doubling you over with abdominal pain. While taking care of you and your gallbladder, the doctors noticed that your blood pressure is elevated. So they adjust your blood pressure medicines to bring it back down to normal. Everything seems hunky-dory.


But if you don’t get close and careful follow-up, those blood pressure pills could do more harm than good.


In a recent post, I showed how common it is for patients to receive antibiotics in the hospital even when those drugs will do more harm than good. Well here’s another harmful practice: adding new hypertension medications to patients whose blood pressures jump up during hospital stays.


To read the rest of this article, please visit Forbes.

Why The Government Tried To Fix Primary Care And Failed

Americans spend more per-capita on medical care than just about any other country and, yet, they often have little to show for it. Americans have worse access to care than people in other countries, and are often less likely to receive primary care services, like preventive therapies and screening tests. Determined to address these problems, Medicare leaders have been testing out new models of primary care, hoping to find win-win situations – reimbursement schemes that improve quality while maintaining or lowering the cost of care.
So far, many of those efforts have failed.
Near the end of 2012, Medicare began giving extra money to almost 500 primary care practices across the US, money the practices used to try to improve the care they offered to their patients. The goal of this Comprehensive Primary Care Initiative was to prod primary care practices to make it easier for patients to: contact providers quickly; coordinate care with other specialists; provide care management to patients with complex chronic illnesses; and better engage with patients and their care givers. The extra Medicare payments were decent sized, almost $60,000 per physician per year. The practices could use this money to hire extra nurse practitioners, or to reimburse those who were working odd hours to give patients more access to care, or other efforts.
Medicare not only gave practices these upfront payments, but also offered to give practices extra money if they reduced overall spending for their Medicare population, an incentive known as shared savings.I am a primary care physician and for around 20 years I worked in VA medical centers, a system that, during my time there, did a great job of coordinating care between primary care physicians and sub-specialists, and of offering care management for patients with complex illnesses.
When I practiced in the VA, I often worked closely with pharmacists and nurse practitioners, for example, to address the need of patients with uncontrolled diabetes. So I am very excited that Medicare is trying to invest in and test ways of improving primary care.
Medicare administrators hoped that better primary care would lead to lower costs. Coordinating care with specialists, for example, should reduce unnecessary testing. Better care management should reduce the need for hospital care.
(To read the rest of the article, please visit Forbes.)

Regulation of Nurse Practitioners

In a recent post, I pointed you towards a very nice article by Jason deBruyn about controversies over the role of nurse practitioners in providing primary care. A recent study in the journal Health Affairs showed that when states loosen up their regulations over what nurse practitioners can do, the percent of people receiving primary care from such practitioners grows.
It’s important to note that the percentages still remain quite low. I don’t think physicians should feel incredibly threatened by this. The primary care needs of our country are growing faster than physicians can meet them. We are all in this together.
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Expanding the Role of Non-Physicians in Primary Care

I’m back to blogging again, and thought I’d return to a topic I have blogged about recently: expanding the role of non-physicians in primary care. A very talented journalist in North Carolina, Jason deBruyn, wrote a nice piece which I am indenting below, laying out some of the controversies.

Debate settles in on costs versus quality of care
Jason deBruyn
Staff Writer- Triangle Business Journal
Email  | Twitter
RALEIGH – Health care economists largely agree that expanding the role of nurse practitioners in primary care would likely decrease overall health care costs.
But it could also reduce the level of care that patients receive because nurse practitioners do not go through the same lengthy schooling and residency training as do medical doctors.
As the nation continues to search for ways to reduce health care spending, considering the cost-benefit of costs vs. level of care becomes a factor in the equation.
Physicians argue that their time in medical school and residency better prepare them to catch a rare case if they notice something unusual about a patient. That might be true, but the overwhelming majority of primary care visits are for patients with diabetes, high blood pressure, or other relatively routine issues. For a vast majority of these cases, nurse practitioners are equipped and trained to provide the proper care.
Dr. Peter Ubel, a medical doctor, behavioral scientist and a professor of public policy at Duke University, says the same debate can be kicked up a food chain one level. Thyroid specialists, for example, would be better equipped than primary care physicians to catch a rare or specific thyroid illness, but for the majority of patients, primary care physicians can properly diagnose a patient and refer her or him to a specialist if needed – and do it at a lower cost.
By presenting to primary care physicians, instead of more expensive specialists, patients receive care that is good enough but at less cost. Nurse practitioners make that same argument one step down, saying they can provide care that is good enough and refer to doctors and specialists as needed.
“For many primary care visits, you don’t need four years of medical school and three years of residency,” Ubel says. “We could save a lot of money with very little medical harm.”
Many states have reduced regulations on nurse practitioners, allowing them to fill in primary care gaps. There is no published study that analyzes health outcomes in states with strict nurse regulations against states with looser nurse regulations, partly because eliminating all other variables is nearly impossible.
Looking purely at the economics, however, reveals probable savings. By using Texas as a model, Ray Perryman, nationally known economist and CEO of the Waco, Texas-based Perryman Group, estimates immediate savings of $16 billion in the health care market by greater use of nurse practitioners and other advanced practice nurses.
Elsewhere, a group led by Robin Newhouse, a registered nurse and chairwoman of the Organizational Systems and Adult Health at the University of Maryland School of Nursing, found consistent evidence that cost-related outcomes such as length of stay, emergency visits, and hospitalizations for nurse practitioner care are equivalent to those of physicians.
Cost-effectiveness starts with academic preparation. With less schooling and residency training, the American Association of Colleges of Nursing has long estimated that the preparation costs for nurse practitioners are between 20 percent and 25 percent that of physicians. In 2009, for example, the total tuition cost for nurse practitioner preparation was less than the cost of one-year tuition for medical preparation, according to the association.
Similarly, the association reports lower salaries for nurse practitioners. Using data from the American Medical Group Association, total compensation for primary care physicians ranged from $208,658 for a family physician to $219,500 for internal medicine. By contrast, the average full-time salary for nurse practitioners across all types of practice was $97,345, according to AANP.
Especially as more people begin buying health insurance next year under the Affordable Care Act, gaps in primary care could grow larger. Physician shortages, particularly in the field of primary care and in rural areas, have been widely predicted for two years now.
“The economic pressures are growing so much that we are at a stage that we are more willing to expand the role of nurse practitioners and advance practice nurses,” says Ubel. “(For primary care,) it’s better to see a nurse practitioner next week, than wait three or four weeks to see a primary care physician.”

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Will a Nursing Surplus Make Up for a Primary Care Physician Shortage?

I wrote not too long ago about a way to overcome the potential shortage of primary care physicians, the shortage some experts worry about because of the increased demand for primary care that will be created by Obamacare. I promoted the idea of primary care physicians teaming with allied healthcare professionals, so they can manage larger panels of patients.
A recent article in the New England Journal of Medicine shows that recent increases in nursing school graduates may be available to help offer primary care to more patients. Look at the staggering increase in the number of people graduating with RN degrees over the past 30 years:


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Dramatic Primary Care Changes in Ontario

Healthcare systems are big and complex beasts, that are very hard to transform overnight. In the United States, for example, we have long had a system of care dominated by fee-for-service payment. In this kind of system, the more tests and procedures and office visits that a physician orders, the more that physician gets paid.
A little over 10 years ago, fee-for-service also dominated primary care practice in Ontario, Canada. You can see that with the light blue area in the circle on the left. But look what is happened in the past 10 years! System has dramatically shifted away from fee-for-service. And guess what? Primary care physicians in Ontario have greater job satisfaction than they had a decade ago.

If you want to read more about this transformation, check out the article by Brian Hutchison in the April edition of Health Affairs.
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Why the Free Market Isn’t a Cure-all for Healthcare

It’s comforting to think that most healthcare problems in the U.S. could be solved by letting the power of an unregulated free market do its work.
It’s also wishful thinking and overly simplistic, according to Peter Ubel, MD, a general internist, behavioral scientist, and Duke University public policy professor who blogs for Forbes and The Atlantic.
That’s a sentiment that many of his fellow physicians would dismiss out-of-hand, so don’t let it be said that Ubel shies away from controversy.
In his writing, Ubel has explored whether physicians should pray with their patients. He’s asked whether the primary care shortage is a myth and asserted that physician pay is too high in the United States. He’s theorized that more transparency in healthcare could actually increase prices… (Read more at Medical Economics)

Solving the Primary Care Physician Shortage by Turning PCPs into Anesthesiologists

Are there really too few primary care physicians? And if so, what can we do to solve the PCP shortage? The standard answer to the first question is “yes, we have too few PCPs.” And the standard solution is to train more such docs, or allow more foreign-trained primary care docs into the country or, better yet, simply pay PCPs more money, so that graduating medical students will be more likely to pursue such careers.
I have a different set of answers. To the first question, of whether we have a PCP shortage, my answer is: “Maybe yes, but very possibly no.”
Keep in mind, before you rush to judge my answer, that I am a proud primary care physician, trained in general internal medicine. Coming out of residency, I was happy to achieve lower pay than my subspecialty colleagues in order to experience the pleasures of taking care of “the whole patient”…(Read more and view comments at Forbes)

Do U.S. Physicians Make Too Much Money?

In September of 2011, Laugesen and colleagues looked at why health care in the US costs so much. Part of their analysis explored primary care physician fees. It showed that primary care docs in the US make a bit more, per office visit, than their colleagues in 5 other countries. But Americans are much less likely to have an appointment with their primary care doctors.

In other words: we can’t blame the cost of US health care on expensive primary care doctors scheduling a bunch of unnecessary visits.
Laugesen also looked at orthopedic surgery in the 5 countries.  Once again, the cost of American health care can NOT be blamed on the volume of procedures we do here.  Instead, it is the amount of money we charge for those procedures!

And the bottom line, for these physicians, is predictable, as shown in these income figures:
This raises a huge challenge.  If we want to control medical expenses in the US, we need to do lots of things. But among them, we need to tackle physician pay, especially procedural-subspecialty physician pay. Good luck going against those interest groups! (Click here to view comments)