Economic Transformation in Health Care - new commentary by Dr. Peter Hilsenrath now available on The Journal of Rural Health website under "Early View." In a country that spends more and often ranks lower in health outcome measures, we all recognize the need for greater efficiency in health care. But how do we get there, especially in rural areas where the number of people 65+ is expected to double between 2000 and 2030?
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Response to Hilsenrath's commentary
Randall Longenecker, MD
June 7, 2013
I really like Dr. Hilsenrath's commentary! I think it is important to call people's attention to it, so that rural folks can start to frame their efforts better in economic terms. However, I have a few comments in response to specific sentences
"Historically, rural regions have been relatively unsuccessful with health maintenance organization programs due to lack of patient critical mass and low provider supply."
and
"Global payments pose problems for rural areas, where providers are more likely to be geographically separated and forced to refer patients outside of their immediate area."
Interestingly, in our rural practice, we did quite well under managed care! Because the physicians in our group were all comprehensive generalists, including hospital care and OB, we were able to meet most needs of our covered patients, rarely requiring referrals and, like comprehensive primary care providers in the rest of the world, keeping people out of the ED and hospital. We did very well financially on our PMPM allotment. The lack of "patient critical mass" was the managed care organization's problem, because they could not leverage contracts with only a few other providers in our county. It was the HMO that asked to be let out of the contract after 3 years, and subsequently (6 months later) went bankrupt!
"On the other hand, there is a limit to what secondary providers are trained for and allowed to do. The services which secondary providers offer may become more of an issue as patient complexity increases, such as an elderly patient with multiple comorbidities and complex medication regimens."
Although this is true, especially for recent graduates of urban residency programs, it is not universally true for rural physicians, especially comprehensive generalists trained in rural places.
Comprehensive generalists are less expensive than specialists, not mainly because they make less money (as much as 3.5 M less that specialists over a career), but because of how their skills and decisions impact costs downstream. My daughter recently ended up with a $15,000 bill for a simple UTI that only warranted a $5 prescription for an inexpensive antibiotic, and only because she fainted!