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Friday, September 10, 2010

Is more primary care really not the answer to all that ails U.S. medicine after all?

A recent WSJ article reports a Dartmouth Atlas study (DA study) that seems to cast at least a little doubt on the thesis that the key to good health care is lots of primary care docs. See here. See here for a more detailed discussion from the blog ACP Internist about the findings of the DA article.

So ,why are the indicators of good care used by the Dartmouth folks not better in an area where more primary doctors are available? The authors make several suggestions? I offer another. Maybe use of aggregate data often makes things less rather than more clear. A similar argument has been raised by some economists in their criticism of the major role of aggregate demand in Keynesian economics namely that the aggregation obscures more than it clarifies.

OR maybe the indicators purported to be of quality care are little more than something chosen because it was easy to measure and the data were available.

I think the real bottom line in regard to this Dartmouth publication is found in the authors' hypothesis that perhaps primary care is really the answer to much of what ails medicine only if that primary care is integrated into a larger system of other health care providers. This is the it-takes-a-village-to- provide -health- care type thinking. Can you say Accountable Care Organization (ACO)?

For the centrally managed health care that Obamacare portends to succeed at least one obstacle has to be overcome. That obstacle is the thousands of individual primary care docs out there practicing outside of the control of an organization such as an HMO,giant clinic or ACO. The Dartmouth publication could be part of a emerging argument similar to that put forth in a recent article in the Annals of Internal Medicine written by members of the administration urging physicians to get on board with the [Obamacare] program. See Dr. Rich's recent commentary about that article and what the message of that was.

What follows is a quote from the White House authored Annals Internal Medicine Study followed by a quote from one of the authors of the DA study.

"These reforms will unleash forces that favor integration across the continuum of care. Some organizing function will need to be developed to track quality measures, account for and manage shared financial incentives, and oversee care coordination…"

"Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage," said David C. Goodman, MD, MS, lead author and co-principal investigator for the Dartmouth Atlas Project. "Policy should also focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals."

So, an "organizing function" is needed and someone/ something needs to make sure efforts are coordinated.

The message is that medical care is too important,too complicated, too whatever to be left to the individual patient and his physician.

Here is an earlier quote from the DA folks from there website.

"The availability of excellent primary care is central to high performing health care and favorable patient outcomes. Unfortunately in many regions of the country, residents cannot find the care they want and need."

Attorneys like to find expert witnesses making apparent contradictory statements so they can ask the old classic: Were you wrong then or are you wrong now?

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