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P E R S P E C T I V E :
P G P S T A F F I N G
W E B E X C L U S I V E
4 February 2004
My Dad Was Not A Prepaid Group Practice Patient
A physician-writer reflects on
his father’s final illness
and the lack of coordination in his father’s care.
By Fitzhugh Mullan
ABSTRACT:
The author’s father was a psychiatrist, a concerned citizen, and a Medicare
patient. He died recently after a prolonged illness during which a panoply of
physicians cared for him in ways that were sometimes redundant, inefficient,
and poorly coordinated. He was definitively not a prepaid group practice patient.
The author reviews the growing body of evidence that suggests that physician
density is associated with greater costs but not improved outcomes. He reflects
on his father’s concerns with equity in health care and how prepaid managed
care might have provided more efficient and less expensive medical coverage
for his father’s final sickness.
My dad died last year at the age of ninety-one. He was a psychiatrist in private
practice for most of his career. Over time, however, he became interested in
the ethics of medical care and concerned with the distribution of health services
in the United States. In latter years he taught group therapy to family practice
residents and joined the liaison group on bioethics at the National Institutes
of Health (NIH). Although the care he received in his final illness was good
by clinical standards, I don’t think he would have been happy about it.
The short story of Dad’s illness is that at age ninety he was admitted
to a hospital in Washington, D.C., with severe abdominal pain. His devoted general
internist of many years had retired the year before, and his new internist was
busy, disorganized, and did not like hospital work. It was a surgeon who admitted
Dad to the hospital and who called a gastroenterologist in consultation. Together
they diagnosed gall bladder disease and appendicitis, straightforward enough
conditions but potentially lethal in a ninety-year-old. Before surgery, they
called in a cardiologist and a pulmonologist to advise them about his heart
during surgery and his lungs afterward.
Dad withstood the surgery, but his mind and body never really recovered. His
pre-surgical confusion became permanent disorientation, his memory never returned,
and his physical recovery was slow and partial at best. The surgeon provided
excellent follow-up care. The cardiologist, pulmonologist, and gastroenterologist
remained attentive. Because Dad continued to show signs of infection, the surgeon
asked for an infectious disease consultation. Because of his continued confusion,
the gastroenterologist asked for the advice of a psychiatrist (who treated him)
and a neurologist (who did not), both of whom continued to visit Dad regularly.
This herd of skilled clinicians had assembled itself with little planning and
no coordination. A weekday morning in Dad’s room during the latter part
of his stay was a social event with one affable physician after another stopping
in.
The surgeon remained Dad’s principal physician throughout his stay. Since
Dad’s internist was the one physician who seemed never to visit, we asked
another general internist to “follow him,” anticipating the need for
a post-hospital physician. This latter physician joined the ranks of Dad’s
visitors but, arriving late as he had, did little to coordinate or manage the
care. When it was decided to discharge Dad to a nursing home, the internist
bid us farewell, explaining that he never made nursing home visits.
The surgeon did a good job of treating a frail, elderly man with a life-threatening
surgical emergency. The variety of medical subspecialists who cared for Dad
did creditable jobs, but their communication with one another and with us, his
family, was haphazard at best. Most of the specialists involved continued to
make regular rounds throughout Dad’s hospitalization, writing notes (some
of which were more legible than others) and ordering tests or procedures from
time to time. No egregious errors were made, and although it was difficult for
us to keep track of who was in charge of what, Dad probably left the hospital
in as good a state of health as we might have hoped for.
Typical Experience
Dad was not a prepaid group practice (PGP) patient. He had Medicare: traditional,
fee-for-service, indemnity-based Medicare. Dad’s care was unarguably generous
but patently inefficient and doctor-intensive. Medicare paid the lion’s
share of the bill, and his Medigap policy covered most of the rest. My mother
dutifully filed the masses of paperwork she received and paid the few bills
that remained.
Yet Dad would not have been pleased with his hospital experience. He would have
been disturbed because the poorly coordinated, specialist-intensive, unnecessarily
expensive care that he received would have been at such variance with the carefully
managed PGP setting documented in Jonathan Weiner’s paper. Fairness in
the system was at the top of Dad’s concerns. His life as a practitioner
and his increasing interest in the ethics of medical care led him worry about
the ability of U.S. medicine to reach all U.S. citizens and, in future years,
to continue to provide for the elderly. He would have found Weiner’s paper
valuable because of the documented efficiency of the clinical workforce in the
PGP setting. He would have known, as well, that his experience, not the PGP
experience, was much more representative of the physician care of well-insured
American patients.
Examining Variations
The variability in the use of physicians is a core issue for the future of health
care in the United States. Weiner’s paper is one more piece of evidence
that medical care can be delivered by a mix of providers that is far leaner
than the norm in this country. John Wennberg and his colleagues have documented
that the more than twofold variation in Medicare spending per enrollee in U.S.
cities is attributable to specialty visits and hospitalizations.1
Elliott Fisher and colleagues have demonstrated that the variation in costs
of Medicare patients is explained largely by more inpatient-based and specialist-oriented
pattern of practice observed in high-spending regions—regions that show
no benefit in clinical outcomes.2 David Goodman
has shown similarly that the more than fourfold variation in the number of neonatologists
per birth across U.S. communities provides no benefit beyond the most marginally
served areas.3 Weiner’s work adds to these
powerful analyses by demonstrating that PGPs provide care with a provider mix
that is roughly 30 percent lower than the national provider-to-patient ratios.
This finding should be of value to future discussions about health care reform
and should give pause to those calling for the immediate expansion of the physician
workforce.4 By implication, it suggests that the
unrestrained conjunction of enthusiastic clinicians and well-financed patients
makes for a costly and inefficient health care system—the one that my dad
experienced.
Epilogue
Dad died in the nursing home six months later, cared for by a geriatrician and
a nurse practitioner. Terminal events are not easy, and I know Dad would have
had a lot to say about everything he went through. The ethicist in him would
surely have been disturbed about his Medicare hospitalization and the lavish
inefficiency of his physician care. He would have appreciated the skills of
the physicians who tended to him, but he also would have been disturbed by the
extravagance of their numbers, the irrelevant visits, the overlapping roles,
and the striking absence of coordination. I can hear him asking if some of his
team couldn’t usefully have spent time seeing other patients who needed
services more than he did. He would have wanted his care to reflect good custodianship
of the country’s medical wealth. PGPs’ use of physicians as documented
by Weiner would seem to embody the essentials of such an approach.
NOTES
1. J.E. Wennberg, E.S. Fisher, and J.S. Skinner, “Geography
and the Debate over Medicare Reform,” Health Affairs, 13 February
2002, content.healthaffairs.org/cgi/content/abstract/hlthaff.w2.96
(8 January 2003); J.E. Wennberg, “Unwarranted Variations in Healthcare
Delivery: Implications for Academic Medical Centres,” British Medical
Journal 325, no. 7370 (2002): 961–964; and E.S. Fisher and J.E. Wennberg,
“Health Care Quality, Geographic Variations, and the Challenge of Supply-Sensitive
Care,” Perspectives in Biology and Medicine 46, no. 1 (2003): 69–79.
2. E.S. Fisher et al., “The Implications of Regional Variations
in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care,”
Annals of Internal Medicine 138, no. 4 (2003): 273–287; and “Part
2: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine
138, no. 4 (2003): 288–298.
3. D.C. Goodman et al., “The Relation between the Availability
of Neonatal Intensive Care and Neonatal Mortality,” New England Journal
of Medicine 346, no. 20 (2002): 1538–1544.
4. R.A. Cooper et al., “Economic and Demographic Trends
Signal an Impending Physician Shortage,” Health Affairs (Jan/Feb
2002): 140–154.
Fitzhugh Mullan (fmullan{at}projecthope.org)
is a practicing physician and contributing editor of Health Affairs.
Please click on the author's
names to read related papers by Jonathan
Weiner, Francis
Crosson, W.
Bruce Fye, David
C. Goodman, Edward
Salsberg and Gaetano Forte, and Stephen
C. Schoenbaum.
DOI: 10.1377/hlthaff.W4.70
©2004 Project HOPE–The People-to-People Health Foundation, Inc.
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