Guest post by Stephen C. Schimpff, MD
We are often told that the reason for the high cost of medical care is all of our new technologies and drugs. There is an element of truth in that but when used correctly, new technologies save lives and improve the quality of patient care and often improve safety. But technologies used inappropriately increase costs while not improving quality and may adversely impact safety.
Here is a patient example:
An older woman had been coming to the same primary care physician (PCP) as her daughter for over twenty years. She lived in another city about 30 miles distant but she preferred to visit the doctor with her daughter. She also occasionally saw a doctor near her home if she had an immediate problem.
ON nearly every visit she said that she felt “tired.” Repeated history and exam over twenty years revealed no cause nor did logical tests such as those for anemia or hypothyroidism. She then developed syncopal episodes – times when she would black out and fall to the floor, once bruising her head when she fell against the stove, and then waking up in a few minutes. Evaluation by the PCP showed that she had intermittent episodes of bradycardia, or very slow heart rate, resulting in the drop attacks.
Consultation with a cardiologist
In consultation with a cardiologist, it was decided to insert a single lead “demand” pacemaker. The pacemaker is implanted under the skin on the upper chest and a wire or “lead” is tunneled under the skin to a vein in the neck and from there into the heart where it is positioned against the wall of the ventricle. The pacemaker senses the electrical action in the heart and when the rate drops below a set level, it begins to send out an electrical stimulus – on demand – to the heart muscle so that it will contract at a normal speed or rate.
The pacemaker is expensive and the procedure to place it is expensive as well. But it worked perfectly and she no longer had the attacks that were not only scary but seriously impacting her quality of life.
A few months later
A few months later, she went to the internist in her home town for an unrelated reason; he urged her to see a cardiologist colleague of his near her home. The cardiologist in turn recommended that she needed a “dual lead” pacemaker instead of the single lead one she had. [It has been found that having more than one lead can sometimes improve the heart’s output for very carefully selected patients with heart failure.]
Her daughter reported this recommendation to the long time PCP who noted that her mother did not have heart failure, just syncopal attacks. Further, the current pacemaker was only needed about 12% of the time meaning that her heart beat at a normal rate at least 88% time, so the pacemaker was not even active most of the day. It was quickly agreed that Mom did not need the proposed new, very highly expensive pacemaker. No pacemaker, no procedure, no risk of insertion. A lot of money was saved and the patient was spared a straight forward yet somewhat risky procedure – which she did not need.
A new dual lead pacemaker
Why did the cardiologist suggest the new dual lead pacemaker? Because, as always, the patient had reported that she was “tired.” He interpreted this as possibly meaning heart failure and that the extra “oomph” of the dual lead pacer would give her more energy. Interesting theory but if he had been more thorough in his history taking or had called the PCP, he would have realized that this was not a new problem nor one to be resolved technologically. Once the PCP became aware and intervened, an unnecessary procedure and device were avoided. [A less charitable theory is that the cardiologist stood to benefit substantially from doing a procedure but not from a simple consult visit.]
The lesson is one doctor needs to be the orchestrator of all of the patient’s care. A good PCP, like this one, coordinates the care of his or her patients with chronic illnesses and in so doing avoids excess referrals, tests, procedures and hospitalizations along with unneeded drugs or devices – all the elements that drive up the total cost of care – and in the process assures quality care, safer care and a close doctor-patient relationship.
We would love to hear from clinicians and patients. What do you feel is needed for better care coordination between primary care physicians? The patient’s daughter informed her mother’s long time PCP about the new recommendation for a dual lead pacemaker; would you have done the same? Please share your thoughtful insights with us?
About the author
Stephen C. Schimpff, MD is a clinician, researcher, educator, retired CEO of the University of Maryland Medical Center, professor of medicine and of public policy at the University of Maryland and author of The Future of Medicine – Megatrends in Healthcare.” He is working on a sequel on problems and their resolution in healthcare delivery. Dr. Schimpff’s web site is MedicalMegatrends and he blogs at this website.