Monday, February 27, 2012

What's in your health care shopping cart?

A few years ago, we received a letter from a physician reader who complained that the approximate prices of drugs provided in AFP were often quite different from the prices he found online or in his local drugstore. This letter ultimately led to a re-evaluation of the rationale and process for estimating drug costs in the journal, as AFP editor Jay Siwek, MD explained in this January 2010 editorial:

Given the difficulties of arriving at the cost of a course of therapy or a one-month prescription, and the wide range of prices possible, we wondered whether it was worth the trouble. So, we did what we regularly do when faced with questions like this—we surveyed our readers. The answer was loud and clear: you want representative prices listed, for generic and brand name drugs. You also prefer an actual dollar amount, or range, rather than using symbols such as $–$$$, as some drug formularies do. And, you found this information helpful when deciding among drugs or when counseling patients.

Although having information about the costs of drugs can be helpful, physicians are often unaware of the costs of common tests, procedures, and referrals. A recent commentary in JAMA argues that electronic medical records should incorporate such cost information to make clinicians aware of the overall costs generated by office visits and other health care encounters:

What if every time a practitioner used an electronic medical record system to order a procedure or test for a patient, an electronic shopping cart appeared, indicating how much that “purchase” would cost? What if at the end of the day the practitioner received a statement indicating precisely how much money he or she had ordered to be spent on behalf of patients? What would happen? Would anybody care? Some evidence suggests that providing this type of information to physicians may be helpful. For instance, in a study at one hospital, following the initiation of a weekly announcement informing the surgical house staff and attending physicians of the actual dollar amount charged to non–intensive care patients for laboratory services (ie, daily phlebotomy) ordered during the previous week, there were reductions in daily per-patient charges for laboratory services, with estimated cost savings of more than $50 000 over the course of the 11-week intervention.

The American Academy of Family Physicians has partnered with the American Board of Internal Medicine and several other physician and consumer groups in the Choosing Wisely campaign, an initiative to promote more efficient use of limited health care resources. Although this campaign focuses on reducing use of tests or procedures that have no clinical benefits (e.g., imaging for uncomplicated low back pain, antibiotics for upper respiratory infections), it raises the question of whether physicians should take responsibility for controlling costs of health care beyond simply eliminating "waste." For example, should family physicians' virtual "shopping carts" drive more selective use of health services that have high costs and marginal benefits (e.g., coronary CT scans, cancer screening in patients over age 75 years)? Or is this type of thinking unjustified and unethical rationing? What's your view?

Monday, February 13, 2012

The state of family medicine is ... ?

A special report on "The State of Family Medicine" in the current issue of AFP's sister publication, Family Practice Management, reviews data from 2011 Residency Match and American Academy of Family Physicians' member surveys to arrive at a mixed conclusion about the current status of the specialty:

On the one hand, family medicine has its challenges, including administrative hassles, a lack of support in the health care system, and threats to its comprehensiveness and scope of practice. On the other hand, family medicine has a lot going for it, including recent efforts to create primary care incentives, incomes well above the national average, and solid evidence of its value to the health care system.

Although the glass may appear to be either half-full or half-empty for today's family physicians, depending on one's perspective, there is a widespread consensus that there aren't nearly enough of us to handle the projected millions of new patients who will be seeking primary care as the result of health reform. An article published in last week's Washington Post quoted AAFP President Glen Stream, MD and Robert Graham Center for Policy Studies in Family Medicine and Primary Care director Robert Phillips, MD, MSPH on the urgent need to address the economic realities that drive many students away from careers in family medicine and primary care.

Since 2000, AFP has published a series of One-Pagers produced by the Graham Center that examine broad historical trends in the scope and practice of family medicine, the impact of policy changes on the primary care workforce, and the often underestimated benefits that primary care physicians bring to the U.S. health system. Collectively, they are an invaluable resource for illustrating the current "state of family medicine." The full text of each of these One-Pagers is available online without access restrictions from the date of publication.

Wednesday, February 1, 2012

How many referrals is too many?

Most AFP review articles about conditions that may require co-management of specialists contain a short section or Table titled "Indications for Referral." For example, the January 1st article on prevention and care of outpatient burns includes a list of criteria from the American Burn Association for considering the transfer of a patient to a burn center. This and other lists generally represent expert consensus on appropriate reasons to refer a patient in a typical primary care setting; obviously, availability and accessibility of specialists has a large influence on a family physician's practice with regard to management of "referable" conditions. Clinicians' training and expertise also affect their comfort levels in caring for patients with complex problems and, as previous studies have shown, these factors lead to variations in referral rates.

Despite variations in referral rates among individual physicians, there is a clear trend in the U.S. toward more referrals. An analysis of ambulatory care survey data from 1999 to 2009 recently published in the Archives of Internal Medicine found that the probability that an office visit resulted in a referral nearly doubled during this time period, from 4.8% to 9.3%. It isn't clear why this is happening, or what percentage of those referrals are appropriate. Medicine may be becoming more complex, or patients may be presenting with more problems that cannot be effectively dealt with in an office visit that is the same length as it was 10 years ago. What is clear is that at a time when a coalition of national primary and specialty care organizations is leading a campaign to reduce overuse of health care resources, the impact of this dramatic increase in referrals cannot be ignored. But in the absence of evidence-based standards for when to refer, how many referrals is too many? Is this even an answerable question? And if it is, what can be done about it?