Provider Accountability Meets Patient Choice

The health care system overall - and community health centers and family practices are no exception – have been constructed on a very paternalistic model.  We pretend we know what is best for our patients and make a system of comprehensive care that requires continuity, appointments to be kept, and patients to obey our orders for preventive care.  And we are increasing being evaluated and paid on our ability get our patients to comply with all of the preventive and chronic care imperatives that are determined to be today's best practices.

While we are evolving this system, patients are choosing to go to other models of care for urgent issues, camp physicals, immunizations, as well as for simple problems.  They seek problem focused, convenient, rapid throughput visits without being engaged in discussions driven by our advice about other issues and our response to EHR-driven reminders.  

We have to pay attention to what is happening now that new immediate care options are available more and more to our patients and we have to figure out where our comprehensive care model fits in.  I don’t have the answer to this yet but we have been talking about it a lot in our management team meetings.

Imagine that your life is in disorder and its three days before school starts, you forgot to get your child’s immunization updated and need a school physical form filled out.  Our health centers see this as a disruption in our appointment system and have difficulty  accommodating this type of visit in an efficient manner.  

Our patients, however,  can now go to any of a dozen local sources of immediate care and get this done.  I think we need to be able to figure out a way to keep our patients with us, while still allowing them to have a short visit if they need it, to accommodate their last-minute issues (haven’t we all had them at one time or another?) and still maintain them in our practice.   If we stick with our old model of requiring people to get care the way we think it should be done and remain oblivious to their chosen care model and the proliferation of places where they can get it respected, then we are truly in trouble.

The real issue now is that accountability for quality will still lie with their primary care provider team, yet our patients will have more and more choices for more convenient care in between their main chronic illness visits.  How we will adjust our practices to deal with that?

For Medical Students: Primary Care, the Uninsured and Painful Lessons that Lie Ahead

On a rainy and blustery evening last week, I had the pleasure of speaking to an amazing group of first and second year medical students at Downstate Medical School in Brooklyn – part of the State University of New York. I am not sure whether they came for the Thai food or to hear me speak but I had the opportunity to tell stories of my medical school, residency and practice experiences – each highlighting some of the fundamental values underlying primary care. My message was that patients are increasingly demanding primary care as a trusted way of negotiating an otherwise incredibly confusing and fragmented health care system. I stressed that primary care physicians must stay focused on the needs of their patients above all else and that our loyalty and responsibility towards our patients must always remain first and foremost in our minds and actions – unfettered to the maximum extent possible – by advertising and loyalties to our hospitals or peers.

As I wrapped up my comments two questions came from the audience. The first, quite predictably, concerned my feelings about the “government controlling health care” and how I felt about that. I asked if the young woman asking the question from the very back of the room was asking about the much debated “public option” in the current health care plan passed by the House last week and she nodded affirmatively. I explained that the plan does not call for the government to control health care, rather that we would be adding another type of government subsidized and managed health care plan to the already existing government plans – namely Medicaid and Medicare.

A tougher question came from a young man in the front of the room who asked how our community health care system could survive financially taking care of the number of uninsured that we currently cared for. And that question truly cuts to the heart of the health reform debate, though I wasn’t fast enough on my feet to realize it at the time. Our 24 site community health care center network in Manhattan, Bronx and the Mid-Hudson Valley cares for over 10,000 uninsured individuals and provides them with over 35,000 visits a year. I explained that to pay for this we literally cobble together funding from dozens of sources. Our Federal 330 grant pays for some, New York State indigent care funding picks up another piece, and grants that support the care of the Homeless, the care of some uninsured patients affected by HIV and dozens of other grants for sub-groups of our uninsured patients – all go to support this work and keep us afloat. I stood there proud that our organization – the Institute for Family Health – had been able to accomplish this.

Yet I missed a real opportunity to underscore the fundamental reason we need health reform in this country. People need health insurance. Our country cannot depend solely upon health centers like ours as the safety net for everything patients who are uninsured need for their care. They must have coverage to pay for all the essential health care services they need. Primary care is the front end of an entire health care system which must provide access to people for diagnostic services, treatments, hospitalizations and medicines. With people of color 2 to 3 times more likely to be uninsured in New York City providing insurance for everyone is an absolutely essential step towards eliminating racial and ethnic disparities in health outcomes. And with primary care providers already struggling to create viable practice models in underserved areas, only full insurance coverage of the people who need these providers can sustain these practices and attract new doctors to these areas.

I am sorry I missed the opportunity to explain more to the students in Brooklyn last week about the failings of our current health care system. But I am not worried that their education will be lacking for very long. Soon the students will begin their clinical rotations in the hospital and there they will no doubt experience, first-hand, the failings of our current system to provide health care for all our people. They will see people suffering the effects of poorly treated chronic diseases – losing their legs and their kidneys to long-standing diabetes. They will see people with cancers that would have been curable if only they had been detected earlier. They will see people with advanced infections that have gone untreated for days or months and now require prolonged hospitalizations. These lessons will hit hard and perhaps some of them will understand and will choose to become the next generation of primary care physicians and the new champions for needed change in our health care system.

Teaching kids how to save lives... Subtitle: Does anyone remember what the principle export product is of Austria?

It was miserable last night - one of those foggy, drizzly nights when all I want to do is curl up in front of the fireplace with the family. But my schedule had me running from a cocktail party on 5th avenue honoring one of the true heroes of the public hospital system in NYC - LaRay Brown - to Marina Del Rey in the Bronx where Mt. Hope Housing Corporation was honoring Congressman Jose Serrano and State Senator Jose Marco Serrano Jr. I was 2 hours late and dinner had been served already. My table was all the way in the back and since I was quite late I walked right up to the front table where Jose Serrano was seated and kneeled down beside him. Not two minutes later Shaun Belle, President of Mt Hope housing grabbed me suddenly by the arm and pointed me to a woman at the next table over who was choking. The woman, formally dressed in her 30s was standing, grabbing her throat and a man behind her was trying to administer a Heimlich maneuver. He was unsuccessful. As I approached he moved away and I could easily see that the woman had an airway that was completely obstructed. She was struggling to breathe and tears were running down her cheeks. It took three tries for me to clear her obstruction with a properly (I guess) administered Heimlich.

So I went home and talked to my son Conor - 15 years old. Told him the story and watched him doing an English project. He was fascinated and surprised when I explained to him what happened. He had learned the exports of all the major countries in the world (who cares?), could name the capital of every state in the US (who cares?) but wasn't (and won't) be taught a simple technique that could, some day, help him save a life. Neither has he - or my other boys who are older - been taught anything about health (except for watching those old movies about "venereal disease") or the major diseases that effect Americans.

Today we sit in the center of epidemics of diseases that are related to health behaviors - what we eat, how we exercise (or don't as the case may be), how we use (or abuse ) substances such as alcohol and tobacco and medications. Shouldn't every child learn as much about their bodies as they learn about the planets? As much about maintaining healthy behaviors as about religion? As much about first aid and the many ways they can help in an emergency as about baseball or football?

The woman whose life I saved last night was lucky that a doctor was nearby. None of the other dozens of people who surrounded her knew what to do. Those that tried to help her failed because they were doing the Heimlich maneuver the wrong way. A tragedy was averted. But by too close a margin. If the traffic had been just a bit slower, if I had stopped for gas when the warning light went on on my dashboard, or sat at my table at the back of the banquet hall - the outcome might have been very different.

If we taught people in school adequately about first aid, health and disease, preventive care of themselves and their families - there might have been twenty other chances for her life to have been saved. Instead she was saved by good fortune and, perhaps, some intervention from above.

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After the comment posted by Dr Eric Gayle below of the Institute for Family Health, I have added the following information on the Heimlich Maneuver - figures are from http://health.allrefer.com website. Learn these techniques and you may have the chance to save a life.

Figure 1. For Infants









Figure 2. For Children

Figure 3. For adults


Figure 4. You can also do a Heimlich Maneuver on yourself if you have some food lodged in your windpipe.