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Fires and Healthcare
From Blame to Peace

About the cover




Fires and Healthcare

Teamwork is the key to keeping up with the exploding
demand for healthcare.

by Dr. James R. Skee



It has happened twice in Obion County, Tenn. The first time was Sept. 29, 2010. Gene Cranick forgot to pay his $75 annual fee for fire protection. His house caught fire and the city fire department stood by and watched everything burn to the ground. Besides losing his house and all his possessions, he lost three dogs and a cat. The second time was in December 2011, when Vicky Bell lost her home and all her possessions to fire as the fire department stood by and watched. "We just wish we could've gotten more out," she said. The mayor of South Fulton, Tenn., is on record affirming this policy, adding that they cannot allow people to pay on the spot when their home is on fire, because then the only people who would pay the fee would be those whose home is burning.

Most of us reading about this feel that this policy is just plain wrong at some level. What is most unsettling is where to place most of the blame for these events. But we all feel it should just not happen this way. The president of the International Association of Fire Fighters described it as "incredibly irresponsible." Can you imagine the outcry if there had been the loss of human life also? Imagine if a child had been sleeping in one of those burning homes!

Those of us in primary care medicine have been witnessing an analogous situation for decades on a daily basis. Men, women and children go without healthcare services and suffer dearly for it, even die, for lack of insurance. It is not usually as dramatic as fires burning out of control — our government made sure of this when they passed EMTALA laws, which prohibit emergency rooms from turning away patients in need, which they used to do if a patient did not have insurance. Most of the time, however, all an emergency room can offer is a quick temporary band-aid to a chronic problem. Definitive care requires more than an emergency room can offer. The more unfortunate among us deteriorate in a more insidious fashion. This tragedy happens every day here in southern New Mexico, which has one of the highest uninsured rates in the nation.

This is why most primary care and other medical societies support the Affordable Care Act. We see the effect on a daily basis of peoples' lack of health insurance. We also see having a more effective national safety net for healthcare access as something that is decades overdue. Vicky Bell was aware of the South Fulton fire policy, but stated that she thought a fire would never happen to her. For folks working hard to make ends meet, similar risks are taken when it comes to paying health-insurance premiums, which are much more expensive than the $75 annual fee in Obion County.

The Affordable Care Act is not perfect, and those imperfections will surely be vetted in the debates of this election year. The largest imperfection is something that will hardly get noticed during this debate, however, but which will become very apparent once more people actually do get insurance. Will they be able to have access to effective medical care? Whom will they be able to get in to see? Will it have a negative impact on those who already have insurance?

Right now, people in our area can often have difficulty getting in to see their healthcare practitioner in a timely fashion. What will happen in the next few years as "Obamacare" becomes implemented is that "baby boomers" will get a few years older and, as aging takes its toll, they will need more visits and attention from the healthcare system. In addition, it is anticipated that over 30 million more people will gain access to health insurance. Currently, there is an average of 2,300 patients per primary care physician nationwide. It is higher in rural areas such as New Mexico. This number will go up! It all adds up to too much work with too little time. Truly, there is "a perfect storm" brewing.

Those of us in primary care, the foundation of any effective and affordable healthcare — the family practitioners, internists and pediatricians — will be disappearing. For many years now, fewer physicians have been going into primary care because the pay is a fraction of what they can earn as a specialist. So, most of us are approaching retirement age. As unmet demands increase, stress on those trying to provide services under these challenging circumstances will also increase. Retirement will be the solution for many practitioners. So how will folks get access to the care they need? What will be their solution?


At Silver Health CARE, we have been proud to be on the leading edge of many innovations in health care. We set up in-house accredited laboratory services for the convenience of our patients and to aid practitioners with more timely diagnoses. We provided hospitalist services to our community before the term was even invented. We added the first and only Urgent Care to the communities we serve to better deal with life's unexpected illnesses. We added electronic medical records 11 years ago, well ahead of anyone else in our community. More recently, we have had more doctors certified in the "meaningful use" of electronic records than any other practice in New Mexico. So, in response to the challenges of providing primary care that I have outlined above, we are once again committed to developing better solutions than just having a line of cars extending out from every emergency room.

What do you want most from your doctor? Most of us want the same things: We want someone who will listen to us, provide good medical care, order the right tests, make a correct diagnosis, and prescribe the right medications. And, of course, we want all of this without breaking the bank. Our needs do not end there, however — we also want someone who knows us as a person, empathizes with us, and whom we feel comfortable with. Sir William Osler, the leading physician educator of his time, said it best: "The good doctor treats the disease; the great doctor treats the patient with a disease."

What do employers and insurance companies want from your doctor? In a word, efficiency. They want us to get you well as soon as possible, and at the least expense possible — keeping testing, referrals and medications to a minimum. In addition, they want your doctor to do all the important screening tests that have been shown to keep you healthy and prevent future illnesses and expenses. This includes immunizations, blood pressure checks, screening for high sugars and cholesterol, PAP smears and so on. Oh, yes, they also want complete documentation of all of this.


So how does a doctor accomplish all of this in a 15-minute visit? In a small fraction of an hour, your doctor is tasked with greeting you, updating what has happened to you in your life since you were last seen, updating all that has happened to you medically since your last visit, reviewing your medications, checking for any side effects, finding out what is bothering you, reviewing other pertinent symptoms and history that might have a bearing on your problems, doing an appropriate physical examination, ordering and reviewing necessary tests, explaining all of this to you, communicating with other consultants and healthcare workers, often having to call your insurance company for permission to order tests or treatments he thinks you might need, updating any preventative health measures you might be due for, doing some very technical coding of all that has been done (including choosing from over 30,000 possible diagnostic codes, soon to be increased to over 120,000 choices — for example, the 59 five-digit codes to describe diabetes and all of its manifestations will increase to over 200 codes — all required by the government and insurance companies), writing new prescriptions and, oh yes, making sure medications are on your insurance's formulary, and… finally, documenting all of this as fully as possible because, as far as your insurance is concerned, "if it is not documented, it wasn't done"!

Could you do all of this in 15 minutes? Neither can most practitioners! A recent study estimated it takes 7.4 hours daily to perform all of the recommended preventive care to a panel of 2,500 patients and an additional 10.6 hours daily to meet their chronic conditions. And all signs point toward increasing burdens in the future.

Everyone knows that our healthcare system is ailing, and clearly we are asking more of it than is humanly possible in its current state. There has been recognition across the country that physicians "can't do it themselves." A 2007 study made it clear that the 15-minute visit can no longer do what patients expect and deserve: 42% of primary care physicians report not having adequate time to spend with their patients; 50% of patients leave the visit without understanding the advice their physician gave; because they feel rushed, physicians interrupted their patients' initial statement of their problems in an average of 23 seconds — in 25% of the visits, patients were never able to express their concerns at all.


What can be done? We need to re-envision primary care as a "team" effort so that individual practitioners are not overwhelmed by healthcare demands that they cannot possibly meet. The system, as it stands now, is not sustainable. To solve this problem, there simply have to be more resources that are better organized.

Successful teamwork in healthcare is hardly a new concept: We are used to teams working together in many contexts. In the operating room, a surgeon, anesthesiologist, OR tech and OR nurse all work together smoothly; at the dentist's office, the dentist, dental assistant and hygienist also work together. Primary care is different, however, primarily due to the large variety of conditions and needs that present themselves, making it very difficult to routinize the process. How well would any restaurant run if you could request any of your favorite dishes from your grandma's family recipe book — and expect it on the table in 15 minutes? Essentially, each patient we see can be a unique and complex need to satisfy.




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