A very smart person in the healthcare benefits space wrote that family physicians can’t influence much the top 25 most costly DRGs in hospitals. Here was my response:
There are many reasons this isn’t true. But it’s understandable that a benefits or administrative person would have no inkling of this, because in many cases there is no way for the administrator to see what’s happening on the ground. In the interest of not repeating my points too much, I took the top 10 from the list you referenced and commented below:
· Major joint replacement
o Family docs talk their patients out of unnecessary surgery, inject joints with steroids (which usually more delays the inevitable, to be perfectly honest), and send people to PT instead of the cutters.
o This is invisible to plan administrators and benefits people because there are no CPT codes to report this work of talking patients out of procedures.
· Vaginal delivery
o Family docs prescribe birth control to their female patients, including placing IUDs and Nexplanons.
o BTW, the fertility rate in the US is rapidly dropping. I’m sure it’s more caused by larger social and economic forces than healthcare system forces.
· Spinal fusion
o Family docs talk their patients out of unnecessary surgery, and send people to PT instead of the cutters. They also send them to pain management types, though the evidence for that is pretty weak. A lot of the family docs’ work is in getting the patient to more humbly accept that they will have pain the rest of their life and that there is no magic technology to change that.
o This is invisible to plan administrators and benefits people because there are no CPT codes to report this work.
· Ecmo or trach with mechanical ventilation 96+ hours.
o Maybe some small effects by family docs talking to really sick multi-morbid patients into palliative approaches, both in the hospital after the severe physiologic insult and before they get this bad in their clinics.
o This is invisible to plan administrators and benefits people because the family docs are not fairly paid for this work.
§ There is a CPT code for advance care planning, but it doesn’t pay well and its documentation requirements are burdensome. I’m also not sure how many insurance companies actually pay the code.
· Extreme immaturity, neonate
o Family docs who provide prenatal care may be able to help this rate, a little.o The overwhelming bigotry in the U.S. against family docs delivering babies and providing prenatal care impacts their ability to do a whole lot about this diagnosis.
· Cesarean section
o See vaginal delivery.
o There is evidence that family physicians care for pregnant patients with more social determinant challenges, but have lower C-section rates.
o https://www.jabfm.org/content/34/1/181.abstract
· Cardiovascular procedures with stent
o Family docs make a small dent in this by treating their high-risk patients with statins, and so on.
o Family docs manage chest pain in their office, when appropriate, and don’t tell every patient with chest pain to go to the ER.
§ Especially the more confident, comprehensive family docs. I acknowledge that a lot of family docs lack confidence, especially those who were trained in traditional academic settings. In medical school and their family medicine residencies, they are told by the other ologists that they are too stupid to care for sick patients. Unfortunately, many believe it.
o Family docs treat patients with severe refractory disease by suggesting palliative approaches.
o The 2nd and 3rd bullet points are invisible to plan administrators and benefits people because there are no CPT codes to report this work.
· Psychoses
o Family docs care for more mental illness than the psychiatrists. They manage these conditions in their offices and don’t tell every patient having a bad day to go to the psychiatric ER.
o Their ability to manage these complex patients is hampered by a general CPT coding and payment system that devalues mental health care, especially those with both psychiatric and organic medical disease. Those are easily the hardest patients to care for. It is never easy to sort out which symptoms are organic vs. psychiatric. But family physicians often reassure patients in nebulous situations without ordering scans from head to toe and chem 2000 panels.
o This is invisible to plan administrators and benefits people because there are no CPT codes to report this work or these judgement calls. We don’t get paid to not do stuff to people.
· Septicemia or severe sepsis w/o mechanical ventilation
o Some of the family docs who work in hospitals might be able to impact this a bit, mostly by not over diagnosing sepsis. The challenge here is that the DRGs for the hospitals are so rigged to incentivize the diagnosis.
o There are meta-analyses that basically conclude that the only thing that really changes the outcomes in sepsis is starting antibiotics for the underlying cause ASAP. Family docs might make a bit of an impact here by seeing a sick patient in their office who really needs to go to a hospital and starting antibiotics in their office.
A lot of health benefits people think they understand primary care and its contributions to the health care system — and how things could be better — but they don’t fully. It’s not entirely their fault. If the payers have given us no mechanism to describe the valuable work we do, how would they know? And where is the AAFP doing anything to tell this story to major employers, insurance companies, and policy makers?
If family medicine won’t grow a spine and tell its story more effectively, then its clear that no one else will step in and do it for them.
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