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Wednesday, March 3, 2010

Surprised that doctors overlook heart disease prevention ?

We doctors get a little tired of reading about how our profession overlooks preventive care, when the simple reason is that we are not being paid to do it. Medscape reported today again, that at the American College of Preventive Medicine, a chart review study of over 3000 hypertensive Medicare recipients showed that doctors were missing a large number of opportunities for addressing cardiovascular risk factors, including high blood pressure, high LDL cholesterol levels, and uncontrolled diabetes. This was already found many years ago by McGlynn and colleagues at RAND who found that on average at any visit, about 50% of things recommended in guidelines for ambulatory care were not being done. Now as then, should this be a surprise when the amount of physician time that is paid for by Medicare and most health plans to do all these things is so minimal?

To put this in perspective, this is like doing a study to show the missed opportunity that supermarkets have to make sure people eat fruits and vegetables every day. If you aren't buying and paying for something, why would anyone expect that you will come out with it? It is not the supermarket's responsibility to do this beyond putting out the offerings. The health plans, and by inference the employers, government bodies, and insurers who set them up, which pay for doctors' time on the basis of various diagnostic and procedural maneuvers, and do NOT pay for appropriate quality of preventive care, are to blame for these "missed opportunities".

Most doctors are seeing Medicare follow-up patients in 10-15 minutes and of course they must concentrate on the most pressing issues, leaving little time for prevention. This reflects what their employers or their state and federal governments choosing health plans on behalf of the public, are willing to buy. Office visits by primary care practitioners are not paid enough by most third party payers for practices to be able to schedule the time really needed to address acute problems and prevention. To go through preventive care carefully for those with risk factors and chronic illnesses, together with the understanding of patients' values, lifestyles, and personalities required to select appropriate interventions may require 2 hours of time, rather than the 10-15 minutes physicians are now being paid for. That is just for evaluation of needed prevention, without even trying to discuss with our patients about how to intervene how to improve their motivation to change their lifestyle, etc. Why then would anyone be surprised at the result of these studies?

What does this mean for the average person?

If you are working or self-employed, and under 65, and have enough cash in the bank to buy your own doctor care, then it might be a good idea to save on insurance premiums by getting a high deductible plan that covers as little in the way of office visits as possible. You could then use what you save to buy your own care and consultation for prevention and managing any chronic illnesses you have. You'll get more out of a gym membership, using a personal trainer, enrolling in a weight loss program, and paying fee-for-service for one very thorough preventive care evaluation from a primary care doctor or personal medical consultant or advisor, than you will by using the short doctor visits paid for by health insurance plans. If you can afford it, you could use the extra money to enroll in a concierge internal medicine practice, which usually will provide you with excellent primary care and prevention. However, it may be more economical simply to pay as you go for primary and specialty care when you need it, since the concierge practices cover only primary care.

If you must rely on employer-provided health insurance, or if you are over 65 and a Medicare recipient without savings, you can make sure to go to your primary care doctor as frequently as your insurance plan will allow until all your concerns are addressed. Plan a separate 10-15 minute visit about each of your multiple problems. If possible, you can create a different agenda for each visit and address each of your risk factors for cardiovascular disease, such as obesity, high cholesterol, high blood pressure, diabetes, and inactivity at a different visit. Take advantage of the maximum visits for care that your plan allows for these conditions. Remember, if you get ill because you wouldn't spend money on prevention and management of your chronic illnesses and risks, you will be pay much more in co-pays and deductibles than you would have spent on preventing a heart attack, stroke or other preventable illness in the first place. If you try to cram everything in one visit to avoid another copay, you'll end up being penny-wise and pound-foolish.

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