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“One of the tragedies of American medicine is that the money doesn’t really align with value”–David Meltzer, University of Chicago

2018-05-18

“The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it.”–1927, Francis Peabody, Harvard Medical School professor.

“…1996 study in The American Journal of Public Health. …estimated that more than a third of Americans on Medicare who were 65 and older and who had a regular physician had been seeing him or her for a decade or more — and those with the longest ties had lower medical costs and were less likely to be hospitalized than those with the shortest… [authors] Linda J. Weiss and Jan Blustein, then of the Columbia College of Physicians and Surgeons: “…remarkably little is known about the actual value — in terms of health care processes, outcomes or costs — of long-term provider-patient relationships.” “–NYT, May 17, 2018, “Trying to Put a Value on the Doctor-Patient Relationship”

The article describes a study done by David Meltzer, a primary-care physician and economist at the University of Chicago, that directly compared hospitalists and primary-care physicians as sources of medical care for a panel of high-intensity Medicare patients.  In one arm, the patients would be seen exclusively by the primary-care physician, even when they were in the hospital; in the other arm, care would be split between outpatient primary-care and inpatient hospitalists.

Patients were selected from among those who had been hospitalized in the past year and were therefore at high risk of being hospitalized again; most of them had chronic medical conditions that predisposed them to acute episodes of illness.  Those who volunteered were randomly placed in one of two groups– a group that was assigned a doctor for outpatient care (most of the volunteers did not already have a primary physician) and another one for hospitalizations, and a group that was admitted to a new clinic that Dr. Meltzer established.  In the new clinic, doctors were given a panel of patients whom they followed whether they were at home or in the hospital.

Of course, to make a long story short, after five years the panel treated exclusively did better and saved money over the split panel.  The patients were hospitalized less, were more satisfied with their care, and had better mental health.

“The Mid-Atlantic [Kaiser] Permanente Medical Group, an organization of more than 1,400 primary-care physicians who serve members of Kaiser’s health plan, ran a pilot of the program in 2015. Two physicians were assigned to its 400 sickest patients. Unlike Meltzer’s team, which relies on hospitalists for after-hours care, Kaiser made the doctors available 24/7 and were surprised to find that patients very rarely called late or on holidays and weekends. Still, the number of times they were admitted to the hospital or E.R. fell drastically, by 80 percent, prompting Kaiser to expand the program to seven doctors and 800 patients.”

“To have a relationship,” Meltzer says, “is to mean that the big incentive is to want them to do well because you care about them and to have the time to really understand what that means and deal with it, because sometimes figuring that out just takes time…”

One of the reasons that increasing medical spending has not resulted in better outcomes in the United States is that care has been fragmented and assigned to multiple profit-making entities instead of being applied through an overall supervisor for each patient who has full knowledge of the patient’s circumstances, the authority to give directions, and also the patient’s trust.

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