Search This Blog

Thursday, May 9, 2013

Your Health Care System At Work-A Primary Care Conundrum

Your Health Care System At Work
Today, at 9:00AM I received a call from the school nurse indicating my sixteen year old son was in her office with a very low heart rate (in the 40’s). This in and of itself was not that distressing to me since my resting heart rate was 52 in my twenties,  and it is a family trait. However, between the time I received her call and attempted to contact my son’s primary care provider, I received another call indicating that his heart rate was so erratic they had called 911. The triage system then required that he be evaluated by the fire department paramedic and transported to the local emergency department. Once there, he was admitted and then evaluated with X-rays and other diagnostic equipment. In the meantime, I had called my primary care provider at Washington’s Community Health Plan three times, was on hold for 15 minutes, and been patched through a “call center,” all the while never having spoken with a clinician. So, the delivery of “primary care” to my son was handled by non-primary clinicians, because the primary care provider was not available.
This scenario illustrates one of the problems in our health care system, which is we have a shortage of primary care clinicians.  It is important to note this reflects a dearth of doctors who are willing to work within the basic pediatric reimbursement level, so the patients are forced to pursue other health care options, AKA the emergency department of your local hospital. This method of treatment is of course expensive and abhorred by health care policy analysts, but when you do a root-cause analysis, this pattern is informed by the lack of treatment options for basic health care in the USA.
This scenario happened in Washington State, which is fairly well off financially, and it concerned a child of a parent well versed with the health care system, so you can imagine how this plays out for ESL parents or others with less familiarity. In Washington, Virginia Mason Medical Center has excellent primary care and a  high level of patient safety, based on their Leapfrog Patient Safety evaluations, their Malcolm Baldridge Quality Award, and personal experience. However, the Virginia Mason system is not available to everyone, especially outside the Seattle area. So, where do the children of parents who are not covered under the luxurious private health care system or the realm of Medicare obtain their basic health care? More than likely they have deferred health care, which is to say very little. I can remember going through at least one Minnesota winter with untreated bronchitis, in a district with no school nurse, and with parents who were barely getting by.
  All of this relates to the lack of basic health care for children, a pattern that hasn’t changed in decades. Though the Children’s Health Insurance Plan (CHIP) which provides federal funding for children who are in the lower economic rung of our society ( which turns out to be quite a few at 7.6 million in 2010 alone) has indeed expanded health insurance coverage for acute care for children, has it increased access to primary care?
The problem with primary health care in the United States is it is so reimbursement driven that the patients experience many obstacles to obtaining timely care. In the case of my son, even with the ED intervention, the soonest the “health plan” could see him was several days away. And the Children’s Health Plan is one of the country’s most well-funded programs. Imagine how it is for adults.
Also, nationally children’s hospitals are the most well funded facilities in the country, monuments to our willingness to throw money at the most dramatic health care interventions, but lack of national motivation to provide accessible basic health care for the country. Do we need to have traumatic injuries or cancer to gain access to the best health care in American, it would seem so.
Anyway, the next time you don't approve your school bond issue, think about the lives that are at stake and this is the healthpolicymaven signing off.
This article was written by Roberta Winter, MHA, MPA, health care journalist and advocate.


Anonymous said...

With Healthcare reform looming and the Excanges merely months away we will have to face an additional already overburdened primary care system adding thousands if not millions more people to the system in 2014. Do not get me wrong, I am an absolute supporter of reform, grew up with socialized medicine in Canada and believ totally in the one payor system. How do we then resolve the problem of doctors leaving the field in droves, unable to make a living in primary care. We pay them an appropriate salary. Maybe not all doctors need to make hundreds of thousands a year, maybe some do not want to run a business and run a practice. The government has again missed the boat when it does not deal with the problem and that is often access. The system is broken when in the middle of the day a person cannot see their doctor to get a simple problem resolved. We need more walk in clinics and primary care doctors who can take anyone and be reimbursed reasonably. Doctors need to be able to spend 20 minutes or more with us to help us with out health and care. Many good primary care doctors are solving this problem by joining fee for care primary care clinics. So again, a really good system that pays the practitioner a reasonable amount of money and gives people access to doctors is only available to the well off. If it works for some why can it not work for all. We need to pull our head out of the sand and stard demanding solutions to the real problem, cost of care, appropriate reimbursement for all levels of service and access to primary care without resorting to the ER.

healthpolicymaven said...

Thanks for your cogent response to a health care system problem. My main point is we have skewed our resources to the acute care setting and not the primary care setting, so we need to re-align those. The whole thing with my son was overkill, but we were just a stone in the road of the U.S. health care technology tank that rolled over us. I do think it illustrates how important nurses are in the primary health care, field as this fantastic nurse was persistent and may have diagnosed something life threatening. I of course thanked her profusely.