For most Americans, and I suspect that includes you, your primary care provider, if you have one, has a “panel” of 2500-3000 patients and sees about 24+ per day. That means 20-minute visits but actual face time with you is probably 10-12 minutes. This is simply not enough time to manage someone with multiple chronic illnesses taking numerous prescription medications who almost certainly has a variety of family, financial and emotional issues to boot. So, let’s take a look using a real person as an example of what happens every day.
I introduced Henry in an earlier article; here is his story in more detail. Henry is a 69-year-old widower living alone in a small town about 60 miles from the nearest metropolitan area. He has a small pension and healthcare coverage via Medicare, a Medigap policy, and a Medicare Part D drug policy. He was recently hospitalized in the ICU with a serious urinary tract infection that spread to his kidneys [pyelonephritis] and to his bloodstream [septicemia], and then his lungs [acute respiratory distress syndrome.] This was a recipe for rapid demise, but the needed intensive acute care is where American medicine excels. It was the full court press to save his life, and it was successful.
A week later, he called me and asked for some advice. He was discharged from the hospital to take his former medications plus a few more. He was now to take twenty-three — yes, 23 — different prescription drugs, some once, some twice, and some three times per day, along with one by shot monthly. He was not sure why many of them had been prescribed and asked if I thought he needed them all.
I responded that, at 400 miles distant, I could not be his doctor, but I would review the list and offer some questions he might ask his physician. He sent me the list, and I reordered it by category: two for heart failure (he did not know that he had heart failure!,) two for diabetes, three for high blood pressure, one to lower his cholesterol, a monthly shot of testosterone for impotence, one to shrink his prostate (it was felt in the hospital that an enlarged prostate had been a predisposition to his urinary tract infection), one for depression, an antibiotic to finish up the treatment of his kidney infection and a few others.
I asked him who his primary care physician was and learned he did not have one but went to four different doctors, each of whom treated different issues, and none of whom shared all of his information with each other. Whenever one of them checked his blood pressure, it would be elevated, so that doctor would either add a drug or increase the dosage of one or more.
He told me that it was always normal when he went to the local drug store and checked his blood pressure. I told him it might well be that he had “white coat hypertension,” meaning it was only high in the doctor’s office. Perhaps if he took these regular readings to his doctor, the physician would get him off one or more of the blood pressure meds. Besides, two of the three had a known side effect of impotence. Finally, I noted that he was on one drug to shrink his prostate, yet the testosterone might well be causing some of his prostate enlargement.
Henry’s story represents much of what is not working in the delivery of medical care today. He has four complex, chronic illnesses – heart failure, diabetes, hypertension, and depression. These all require careful attention and care coordination, preferably by a single primary care physician who knows the patient’s home and social setting as well as his direct medical issues.
The blood pressure medication story is representative. He was getting many too many drugs that he did not need and had become impotent as a result. Rather than looking for the cause, he was given another drug [testosterone] that probably had no value but was likely enlarging his prostate. As a result, he developed an infection that almost killed him. The hospital doctors had added a drug to shrink his prostate but left the testosterone in place. And all these drugs were expensive for him and his Medicare Part D insurance plan.
Heart failure and diabetes together consume more than 50% of our healthcare dollars. Here is a person whose care is not being adequately monitored; instead, he is getting one drug after another without attention to what else is happening. This lack of care coordination is a prime reason why the costs are so high yet the quality so low. The problem is less that drug companies charge too much for many drugs (they do) but rather that too many drugs are prescribed unnecessarily or inappropriately.
It is also instructive that Medicare pays without question for intensive hospital care – tens of thousands of dollars in Henry’s case, yet pays primary care physicians minimally – even though with time to listen, think and consider, a PCP could have, with limited costs, prevented the hospitalization.
My first suggestion was that Henry needed a primary care physician, one to call his own. He learned that a young doctor he had met at a nearby hospital would be setting up private practice near his town, so he became one of the first patients. Since the PCP did not have many patients yet, he gave Henry the time needed. A few months later, he called and told me that he was now taking just seven medicines, felt better, and was saving a lot of money.
But during our initial discussion, I also asked him what he weighed. I have known him for over forty years but had not seen him for more than twenty. I recalled a stocky, muscular man with perhaps a bit of a beer belly, so I was surprised when he said he weighed 285 pounds. His wife of more than 50 years had died a few years before and he found himself lonely and isolated. He rarely went out and told me he did not exercise; it was just too difficult. He fixed his own meals, mainly from prepared foods.
I asked him what he planned for lunch and was told soup and a sandwich. The soup was a canned one, so I asked him to read the sodium content to me. It was 320mg, or 35% of the daily recommended amount. The can had “two servings,” but he planned to eat the whole thing or 70% of his daily salt requirement (assuming he was not on a restricted salt intake because of his high blood pressure and heart failure) in the soup alone! The sandwich was salami on white bread with some lettuce and mayonnaise.
That sounded great for his high cholesterol problem. Together we figured out that he ate about 2000 calories per day, which he thought was about right based on the soup can label. I suggested that 2000 calories was about right when he was 22 and in the Army, but now, since he did not exercise and needed to lose weight, this was way too much.
My next suggestion was that he needed to get out, interact with people again, carefully consider his diet and begin a modest exercise program, perhaps just a short walk each day. When he called later, he told me that a friend had gotten him to start going with him to the local senior center, where he had made some new friends. Eventually, he agreed to go to evening dances, where he met a widow whose company he enjoyed. His depression seemed to have lifted; he was exercising and enjoying dancing again. I could hear the smile in his voice.
Henry still has four serious chronic conditions. But with a single physician serving as his primary care physician who was aware of all of his medical, emotional, family, and financial issues, his care became much more effective. And when he did need a specialist, which was now rare, the primary care physician became the orchestrator, not just the referrer. As a result, Henry now has better quality medical care, he has a much higher quality of life, he is spending less of his money and much less of Medicare, Medigap, and Medicare Part D’s money. In short, it is a win-win for all concerned.
The key to improving Henry’s care was to find a PCP who would and could spend the time with Henry necessary to offer such comprehensive care. Today, because of high overhead costs and low insurance payments per visit, most PCPs need to see about three patients per hour. They just do not have the amount of time a person like Henry requires. But those that do provide such time offer much better care. Yes, more time per patient means fewer patient visits per day, so someone has to pay for the difference. Insurance rarely does, which is unfortunate. The patient will have to pay the PCP directly, “Direct Primary Care” or DPC. But as we will see in later articles, the total cost of care comes way down, quality goes up, and patient and doctor become less frustrated. Henry is a great example of how totally dysfunctional care can, quite simply and a very low cost, be converted to excellent, cost-effective care.