Prevention and Primary Care

One main objective of the Affordable Care Act, or health care reform, is to focus on prevention. This has been translated into requiring insurance companies to cover annual physicals and a variety of screening tests. Of course primary prevention is done in the setting of primary care. Unfortunately the government is, in a sense, working against itself because of the current system for determining reimbursement for medical services. Pauline Chen documents this well in her recent piece in the New York Times: How One Small Group Sets Doctors' Pay She writes:

Why are there so many medical specialists in a time when we need more primary care doctors? Meet the RUC, a committee of 29 men and women who play a critical role in dividing the Medicare pie.

She describes the close connection between the RUC and the Centers for Medicare and Medicaid Services, or C.M.S.

First, C.M.S. historically has approved 90 percent or more of the recommendations from the RUC. Second, while the RUC makes its recommendations based on an anonymous two-thirds majority vote, about 80 percent of those voting to begin with — accounting for 23 of the 29 seats — are physicians representing professional societies. Third, almost all of those physicians are specialists (currently only five RUC members are doctors from primary care fields).

Prevention happens through the relationships that develop over time in the primary care setting. Consider this story from my pediatric practice( details, as always, have been changed to protect privacy) Six year old Kevin’s mom, Robin, was upset about his constant fighting with his younger sister. I had taken care of both children since they were infants.

Robin was distraught over Kevin's need to always have everything first, and his demands were escalating. They were having increasing difficulty getting out of the house in the morning. I saw them for 2 fifty-minute visits. The first involved the whole family and we talked about some common approaches to managing behavior. I was struck by Mom’s level of distress, which seemed out of proportion to this fairly typical sibling rivalry. Towards the end of the second visit, when Mom was alone with Kevin, she quietly began to cry. I looked puzzled. She told me of the horrible accident that had taken the life of her older brother when she was a child. Her family never spoke about it. That trauma came flooding back now that she had two children of her own. She recognized that she had to mourn this loss in order to be present with her children in the way she wanted to be.

This was 10 years ago. Recently I ran into Kevin. He is now a talented musician as well as an excellent student. I saw him in town with his arm around a girl. He gave me a big smile and a friendly "hello." Of course I can't say what path his life would have taken had this trauma of his mother's not been addressed. But I suspect that it had a role in freeing him to develop into the person he is today.

Prevention can only happen in a meaningful way if the value of primary care is recognized. This involves not only monetary value. Certainly with the burden of loan repayment, financial issues are paramount in determining what field doctors-in-training chose to go in to. But in addition we as a society need to recognize that listening, particularly listening that occurs in the context of a relationship that develops over time, is an important form of treatment. Prevention is not only about screening tests.