Patient Volleying

Wayne Myers, MD, Look What's Coming columnistby Wayne Myers

“Patient volleying” is a term I’ve coined that may be worth adding to the policy lexicon. When I think of volleying in tennis or volleyball I think of skilled players keeping the ball in play among them for long periods. The medical equivalent is a sad game played for money. This very profitable game is often rationalized in the name of “defensive medicine.” The “players” are otherwise surplus referral specialists, using their own skills, imaging centers, cardiac cath labs, intensive care units, etc. Patients are referred back and forth in very long sequences. The Wennberg group (Dr. John Wennberg et al.) is the national scorekeeper and the Dartmouth Atlas of Health Care the scorecard. Though the game is played with patients of all ages, only Medicare patients are officially scored. The actual score is the Hospital Care Intensity Index (no longer available online), measuring how many resources are used by docs on Medicare patients in particular communities. It turns out that to get really impressively high scores you need lots of referral docs and lots of gadget-rich facilities and intensive care beds per patient.

We’re hearing lots of discussion of a physician shortage, particularly in primary care and most notably in rural primary care. Though the number of osteopathic schools has been growing steadily through recent decades, the number of M.D. schools in the United States has been practically constant since the 1970s. Now there are rumors that a large number of new M.D. schools are being planned.

All the projections of future need are preceded by a disclaimer to the general effect, “As long as we keep using physicians as we do now, we are going to need….” I would add, “As long as we keep using physicians as we do now, we will continue to follow a medical care spending growth curve that will wreck our economy.” In other words, the expansion of medical schools is predicated on unsustainable growth in health care spending. Conversely, if our federal government, watching health spending consume an additional percent of the economy every year or two, develops the backbone to control health care growth, we’ll be exporting surplus docs in a few years.

So much for overall physician numbers. What about primary care? I have to fall back on a couple undocumented memories from our last flirtation with reform in the Clinton era, circa 1994.

Young docs who plan to become pediatric or internal medicine subspecialists apply for fellowships in the summer and fall of their final year of residency. They finish their primary care residencies in June and almost immediately become “fellows” in cardiology or rheumatology or whatever their chosen subspecialty. At that point they depart the ranks of primary care and become subspecialists-in-training.

In 1994 that system broke down. The country seemed to be moving toward health care reform based on managed care. Patients would have primary care doctors as “gatekeepers.” They would have to be “referred” to subspecialists instead of making their own appointments or being referred from subspecialist to subspecialist. Unnecessary referrals would probably be greatly reduced. No more patient volleying. The young docs felt the future in the subspecialties suddenly looked less promising. A substantial proportion of the people who had accepted fellowships when they were offered in the previous fall, failed to show up the following July. The point? If and when physicians-in-training anticipate a shift in the practice marketplace, their career choices will change very quickly.

Though Clinton reform legislation failed, commercial managed care insurance plans were strong, and relied on primary care doctors through the rest of the 1990s. Accordingly primary care doctors enjoyed some level of prestige. Primary care training programs were well subscribed and health care costs grew relatively slowly.

Toward the end of the century the managed care-primary care movement lost momentum as people objected to having to be referred to subspecialists. Health care cost growth took off. Primary care training fell to new lows where it remains. Opening a bunch of new M.D. schools won’t help. In the absence of major system change to increase the value of primary care and reduce the prestige and pay accorded the referral specialties, expanding physician production will be counterproductive. It will just make the surplus of referral specialists worse and increase the prevalence of patient volleying.

This pattern of too many specialists and too few primary care docs was in place when I started medical school 47 years ago. Our society recognizes it as a problem but prefers and preserves this pattern when allocating funds, no matter how badly it hurts us. The enemy is us.

Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health and served as its director. He also served as director of the Office of Rural Health Policy in the Department of Health and Human Services’ Health Resources and Services Administration. He is a past president of the National Rural Health Association.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.

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