I have a wonderful doctor! Can he survive?

Many of my past blogs have been critical of our current health care system.

For several years, I have searched for a primary care doctor for myself.  I was initially recommended to see a "very good" internist.  During our appointment, he never asked me to disrobe and examined me through all of my clothes.  He was more interested in whether I wore seat belts or had fire arms at home than the complaint I had at the time.  The second "highly recommended" internist spent our entire time together looking at his computer.  He never made eye contact with me.

Finally, I was referred to a senior internist who was not accepting new patients.  I called him and asked him to take care of me and he agreed.  My initial appointment took over one hour and he did no typing.  He said that he would spend time later completing the cumbersome electronic medical record. He is a wonderful doctor.

He works for one of the large health systems in Philadelphia and he told me that he is constantly getting complaints from the office manager because of his poor productivity.  He spends time talking to his patients and doesn't see that many patients each day.  He said that a young colleague recently received recognition because he sees an average of 22 patients per day.  BUT my internist loves what he does and is concerned that he might not be allowed to continue in his role.

I recently had some blood work done.  Although my internist was on vacation, he reviewed the blood work, called me to discuss it and said that he would be happy to see me when he comes back to work.

So, the question is, how do we increase the number of physicians who are like mine?

Part of the answer is that we need to change our current reimbursement system so that quality rather than quantity is rewarded. Many health care gurus are talking about this but implementation is difficult.

One option is to assign a population of patients to a given doctor and give him a set dollar amount for taking care of that population (capitation).  Theoretically, he would concentrate on preventive measures and lifestyle modification to keep his patients from getting expensive and perhaps unnecessary tests and laboratory work which would decrease his end of the year income.  He would refer his patients to specialists who take a very conservative approach and do not perform invasive tests on every patient whether or not it is indicated.

But, how can we guarantee quality care and prevent rationing of health care?  Many of our current quality metrics are inadequate and just measure process.  For example, one quality measure is whether or not a foot exam was performed on a patient with diabetes.  This metric does not question whether a peripheral neuropathy was discovered and treated.  Another check off box on the medical record is whether or not the patient received counselling about smoking cessation.  This is a meaningless question.

We need to improve the way that we measure quality so that we can reward our best physicians who spend time with patients and do not recommend or do unnecessary procedures.  This is our hope for the future. It is not part of current Obamacare, which means we have a lot more reform work to do.

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