What you said: Patient-centered health care

Here's what some of you had to say about my Wednesday column about patient-centered health care.

AdaminMiami wondered about my analogy: "You don't pay a mechanic if your car is running fine. You pay him after he fixes it," s/he wrote:

"I don't understand why people think that they shouldn't have to pay for going to a doctor. Our system was originally set up so that health insurance protects you from catastrophic illnesses. The normal everyday checkups, shots, etc were the responsibility of the individual. You want to change the system, change it back to the way it was intended to be!"

Maybe the analogy isn't perfect (although I am paying to take my car in for a tuneup in just a couple weeks so I'm not later surprised by a broken belt or worn-out tire -- fixes which will cost more if I wait for an emergency), but that doesn't mean the idea of a patient-centered medical home is junk.

It's also distinct from the insurance issue. I'm not arguing that no one should have to pay, but that doctors should get paid for more detailed consultations, for coordinating care and for follow-ups that keep us well and better able to manage chronic conditions.

Another reader e-mailed a personal story that shows the benefits of coordinated care (and of paying doctors in a way that makes coordination possible):

"About three years ago, my internal medicine doctor referred me to [University Hospitals] to a specialist, because some blood tests were marginally out of whack. Although it was marginal, and that is where my doctor thought I was unnecessarily concerned, looking at previous tests over previous years (I save them), the climb in results was obvious - year after year, it got a smidge higher, on a steady basis.At U of Iowa I saw two endocrinologists at the same time - a research fellow, and a staff physician. Both, "immediately" referred me to a surgeon, who arranged for confirmatory tests, and - ultimately - surgery, within a month.U of Iowa is the only hospital in this area that allows for free-flow emails between doctor and patient, assuming the doctor accepts them - not all do. The research fellow allowed me to engage in lots of emails, along with the surgeon, and we had e-mail conference "call."As a former pharmacist, I was able to check medical literature, and understand it.To make a very long story short, the surgery was cancelled. I had some role in this, the emails had a tremendous role in this, the "gut feel" of the research fellow had some role in this - collaborative thinking, and the ability to spend an enormous amount of time with a patient played a massive role in this.I avoided surgery that I did not need, which COULD have had terrible outcomes, AND would not have solved the problem.Instead of taking out my thyroid and parathyroid for a cancer I did not have (and then requiring prescription drugs for life), they prescribed Vitamin D supplements, for a Vitamin D deficiency that I had, which cleared up massive symptoms which were diffuse, and nobody attributed the symptoms to anything at all.The above is the very short version of a very long story, part of which is four months of physician visits, and $20,000 in lab tests, for an outcome that now costs me about one penny per day for life.The outcome would not have happened, without my persistence, the ability - and desire - of U of Iowa physicians to communicate with email, the ability of U of Iowa physicians to get paid SALARY and devote the time - if they felt the need, as well as a very persistent research fellow, who insisted that "everyone is wrong" even at moments when he had no diagnosis.

At U of Iowa I saw two endocrinologists at the same time - a research fellow, and a staff physician. Both, "immediately" referred me to a surgeon, who arranged for confirmatory tests, and - ultimately - surgery, within a month.

U of Iowa is the only hospital in this area that allows for free-flow emails between doctor and patient, assuming the doctor accepts them - not all do. The research fellow allowed me to engage in lots of emails, along with the surgeon, and we had e-mail conference "call."

As a former pharmacist, I was able to check medical literature, and understand it.

To make a very long story short, the surgery was cancelled. I had some role in this, the emails had a tremendous role in this, the "gut feel" of the research fellow had some role in this - collaborative thinking, and the ability to spend an enormous amount of time with a patient played a massive role in this.

I avoided surgery that I did not need, which COULD have had terrible outcomes, AND would not have solved the problem.

Instead of taking out my thyroid and parathyroid for a cancer I did not have (and then requiring prescription drugs for life), they prescribed Vitamin D supplements, for a Vitamin D deficiency that I had, which cleared up massive symptoms which were diffuse, and nobody attributed the symptoms to anything at all.

The above is the very short version of a very long story, part of which is four months of physician visits, and $20,000 in lab tests, for an outcome that now costs me about one penny per day for life.

The outcome would not have happened, without my persistence, the ability - and desire - of U of Iowa physicians to communicate with email, the ability of U of Iowa physicians to get paid SALARY and devote the time - if they felt the need, as well as a very persistent research fellow, who insisted that "everyone is wrong" even at moments when he had no diagnosis.

This kind of coordination is already happening in integrated delivery systems like Kaiser-Permanente in California and multi-specialty group practices like the Mayo Clinic in Minnesota (The Washington Post ran this article over the weekend, discussing how the Mayo model may, or may not work on a larger scale).

But back online, Shotfeel defended the current system: "I'd say the fact that life spans continue to rise due to things like higher cancer survival rates and better management of cardiovascular disease shows that we are getting results, and not just racking up tests." 

Yes, but there's general agreement that we're overtesting, and that's for at least a couple reasons. It's how medical providers get paid under the current system, for one. 

A second reason is kind of interesting, and gets back to this idea of strong primary care. At Friday's seminar, several doctors mentioned that if they have a good relationship with their patient they can better explain why some tests aren't medically necessary. If they don't know the patient, they're more likely to sign off on an MRI for a headache, for example, just because the patient thinks they need one.

In other news, members of the Senate Finance Committee 

wrote "value of care" language into the draft health care reform bill earlier this week. That provision would tie Medicare payments to quality of care by 2017. They haven't figured out how that would work, exactly. At last Friday's symposium, University of California-Berkeley School of Public Health Dean Stephen M. Shortell (who studies this stuff) said we've got the data to do it.