Is Substituting Primary Care for Specialist Care Rationing in Disguise?
One of the more persistent memes in mainstream health policy is the assertion that consuming more primary care and less specialist care will reduce health expenditures without damaging health. The Dutch actually do this in obstetrics. In 2004, the European Perinatal Health Report generated a re-examination of the Dutch system with its finding that the Netherlands had one of the highest perinatal death rates in Europe.
The Dutch obstetric care system is unique among the industrialized nations in assuming that pregnancy, labor, and delivery should be treated by primary care providers. Early in their pregnancies, healthy pregnant women choose between a home birth or a short stay hospital birth. Either a midwife or a general practitioner may supervise. About 29 percent of Dutch births took place at home in 2005-2007, down from 35 percent of all births in 1997-2000. Due to a shortage of general practitioners compared to midwives, only about 6 percent of births were supervised by general practitioners in 2002.
Access to an obstetrician (secondary care) is allowed only if complications occur, if risk factors exist early in pregnancy, or if complications arise during pregnancy, labor, or delivery. The indications for referral are laid out in the “obstetric indication list.”
Although the Dutch obstetric system is built on the assumption that experts can accurately assess medical risk, its outcomes suggest that this assumption is incorrect. In a two year study of all babies born in the catchment area of the neonatal intensive care unit of the University Medical Center in Utrecht, which covers 13 percent of the Dutch population, Evers et al. (2010) found that delivery related perinatal death was “significantly higher among low risk pregnancies in midwife supervised primary care than among high risk pregnancies in obstetrician supervised secondary care.” Babies born to “low risk” women under midwife supervision who were referred to obstetric supervision during labor had a more than 3.5-fold higher perinatal death rate than those born to “high risk” women who began labor under obstetric supervision.
Unfortunately, health policy makers in the US seem unable to learn from health system problems in Europe, Canada, and the United Kingdom. In 2011, for example, Appendix B of the March 2012 MedPAC Report to the Congress on Medicare Payment Policy recommends “a 10-year schedule of specified updates for the physician fee schedule” in which specialist reimbursement rates would be cut by 5.9 percent per year for three years and then frozen for the next seven years. Primary care rates would be frozen for 10 years. Primary care “providers” are those who enroll in Medicare as geriatricians, internists, specialists in family medicine, and pediatricians. Nurse practitioners, clinical nurse specialists, and physician assistants also qualify.
People in primary care enjoy protected reimbursements because MedPac believes, without much in the way of evidence, that “the greatest threat to access over the next decade is concentrated in primary care services.” The report defends this conclusion by pointing to MedPAC′s in-house survey of people 50 and over. The reader is told that people were asked how difficult it was to find a new physician. Of the 7 percent of people looking for a new primary care physician in 2010, 79 percent of the 7 percent of people looking for a primary care physician had no problems finding one. Of those looking for a new specialist, 87 percent reported no problems finding one.
It is anyone′s guess if the reported 8 percent difference means anything. It is more likely that MedPAC′s new price controls will simply create shortages of both specialists and primary care practitioners with, as in the Dutch care, dire results for patients in need of expert, high quality, medical care.
A large number of legal, medical, and technical problems only exist because countries refuse to look at data that originates outside of their own borders.
Many countries have more primary care physicians than specialists. In the United States, the ratio of primary care to non-primary care specialties is about equal. The distribution of doctors is related to the politics of medicine, common in countries with socialized health care systems. Most people are healthy. What they really want is to be able to see a doctor when they are sick. The way to maximize votes is to pour resources into primary care (many constituents) and skimp on costly care for the desperately ill (few voters, many of which are too sick to vote).
At the very least, the lower quality health care that people will get from these substitute doctors for certain ailments and conditions is a step toward rationing.
Rationing or simply irrational? Having trained in the trenches in Neonatal ICUs. . . I saw these primary docs with lots of experience and ethics. . . get totally blown away by the inevitable litigation that will swallow up their enthusiasm, time and resources. . . when there is the inevitable neonatal catastrophe. . . which is alleged as malpractice not an act of God. Doctors in other countries do not sit on a witness stand facing the likes of a baby’s attorney such as John Edwards in his glory days.