Seeking a system that respects the patient-physician relationship

Tags: president's letter, legislature, physician, patients, relationship, youens

By Robert Youens, M.D., M.M.M.
TAFP President, 2008-2009

Recently in a neighboring community to mine with practicing family physicians, a hospital, surgeons, obstetrical care, ER coverage and multiple visiting specialists, two interesting developments have occurred. First, a new clinic has opened with a $1 million grant and the backing of the local community and a citizen champion. The plan is to have it qualify as a Federally Qualified Health Center “look-alike” that will allow it to receive Medicare and Medicaid reimbursement at significantly higher levels than the locally practicing physicians. This clinic is able to see any patient: Medicare, Medicaid, private insurance or private pay. Incidentally, the guiding force behind the clinic says they currently have a nurse practitioner and a “family practice” doctor, but he wants to get a pediatrician because his primary reason for starting the clinic is to help children.

Second, with the help of local and federal politicians, a Veterans Administration clinic is to open this summer to care for veterans in the area who need their services, thus decreasing travel distances to a more remote VA clinic. This clinic was awarded on a bid contract to a company who apparently does this in other places and is to be staffed by various ancillary personnel hired for the business as well as a general practitioner from the area.

While at first blush one might ask, “And the problem is?” But the problem is a perpetuation and exacerbation of our fractured health care system. All of these patients, now encouraged to seek help in a government-funded environment, could easily be cared for if primary care were properly supported. The answer to our health care crisis is not the perpetuation and creation of more patchwork clinics that compete with the privately practicing physician. These clinics provide no after-hours coverage, an ethical obligation of a physician in private practice. These are institutional clinics that have physicians obligated by contract to their employer, potentially creating a conflict of interest between the employer and the patient.

This of course leaves the physician out. In the VA case there is no physician-directed, patient-centered medical home and in the FQHC look-alike, the patients “belong” to the clinic and are not necessarily the particular charge of the physician. The FQHC has no apparent plans for evening or hospital coverage other than the directive that the patients should go to the local hospital. The VA is the VA and its patients can either go where there is a VA hospital (100 miles) or they can see if the family doctor they haven’t seen in four years or so could care for them locally.

I’m not specifically upset with the folks trying to care for these populations; I’m upset with a system that does not value the doctor-patient relationship above the institutional relationship. I’m upset with a system that perpetuates our fractured care infrastructure. The people who started these clinics are proud of them and are meeting a perceived need. In the case of the VA clinic, this special population may occasionally need the kind of help only someone in that system can provide. For most of these local patients, their trip to the VA clinic is to get cheaper medicines. The local physicians using the VA formulary could easily provide this.

With regard to the FQHC, the problem is more complex. The local physicians restrict their Medicaid practice, making it difficult for patients in this “class” to receive care. This then creates the need, and the answer becomes an inefficient clinic whose payments are enhanced as the cost to provide care goes up.

In a private clinic, costs are adjusted to create the most efficient and effective delivery system possible. If they received the FQHC reimbursement rates, it is likely the local physicians would consider providing care to these patients. I’m not upset with the local physicians; I’m upset with a system that pays doctors more if they become employees of a government clinic thus worsening our patchwork system creating different classes of patients and different classes of doctors.

We all—doctors, patients and the taxpaying public—will continue to suffer needless harm if we do not establish a robust primary care base of adequately paid physicians. This will only happen with a cogent health care system that does not create different classes of patients and doctors. I’m not suggesting that every patient should have exactly the same coverage, but I hope the current disparity that creates the aforementioned class system will be remedied in the effort to create health care coverage for all.

By the way, congratulations to Tom Banning and TAFP for creating a program through the Legislature that will pay back the loans up to $160,000 of physicians willing to practice in physician shortage areas of the state.

I have enjoyed my year as president of TAFP. The staff of our organization is effective beyond expectation and made my role one more of policy suggestions rather than effort in the trenches.

To all I offer the advice I gave my children, “Give ‘em heck and have fun.”

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