Payal Bhandari, MD Image from MedPageToday

MedPageToday
Primary Care
Primary Pain Points: ‘Ill to Pill’
Published: Jul 10, 2014
By Sarah Wickline, Staff Writer, MedPage Today

“I am frustrated by the healthcare system’s payment model and its ability to value sufficient preventive care,” Payal Bhandari, MD, a primary care physician in private practice at Advanced Health in San Francisco, told MedPage Today in response to the question “What frustrates you?”

The healthcare system is driven on the premise “health is the absence of illness, injury, or disease,” Bhandari said.

Here’s what else she said:

Presumably Ill

Patients who enter into the medical community are presumed to be ill, injured, or diseased. It is then a matter of defining the degree of illness, and what invasive treatment can be offered to prevent patients from knocking on death’s door. The care delivered is rarely under the premise of driving wellness and utilizing the body’s innate ability to self-heal.

Primary care providers spend a great deal of time defining how ill patients are; coordinating which medications, injections, and procedures to prescribe; what tests to order; and which specialist to refer patients to.

The remainder of our time is spent creating extensive documentation to support the complexity of patient visits, billing, and managing this “ill to pill” infrastructure.

Healthcare incentives are not aligned with patient health. Hospitals are financially driven by filling up their beds, operating rooms, radiology, and laboratory centers.

Researchers are driven by creating treatments for every aliment, improvement to every procedure, and better diagnostic tests. Billions of dollars are spent annually on disease detection and treatment while a fraction is spent on the prevention of disease onset.

Symptoms and the Root Causes

Physicians often do not have an incentive to look deeper at patients’ aliments in order to better understand, and treat, the underlying causes.

A recent example was when I met an overweight middle-age patient for the management of his longstanding hypertension. For years, the patient had been under the care of another physician who followed the nationally set hypertension guidelines.

The physician had prescribed the patient many different antihypertensive medications and done an extensive work-up to rule out secondary causes of high blood pressure. The patient was frustrated with his chronically elevated blood pressure despite taking many medications.

When I asked the patient about his daily schedule, I learned he often drank five cups of coffee each day to stay alert from never sleeping well at night.

He often did not feel hungry until evening when the patient would have one large meal with a few glasses of wine. I worked with the patient to decrease his caffeine intake and eat more nutritiously throughout the day.

These changes helped the patient feel more relaxed and lighter causing further decreases to his dinner portions and alcohol intake. As the patient’s sleep improved, his blood pressure began to normalize and his weight began to drop. His need for antihypertensive medication has gradually decreased.

Under his prior physician’s care, the patient had felt disconnected between how his lifestyle could affect his well-being. The patient now felt empowered with the small improvements he was making in positively transforming his health.

The patient was surprised that he had never been asked about his diet, sleep, or exercise habits. I realized patients are often unaware of how lifestyle can dramatically impact their well-being.

Many providers do not help patients make the connection between symptoms and the root causes, nor feel equipped to empower and educate patients on how to make lifestyle changes.

Providers are often convinced that prescribing medication will suffice for lifestyle changes, which may be futile and difficult to alter. The missing link to addressing the underlying causes is the lack of education, time, and providers’ inability to adequately engage patients.

The concept of investigating and addressing the root cause is often never considered in medicine. No wonder there is an epidemic of so many chronic diseases that continues to worsen, and America’s healthcare cost being outrageous.

Physicians are exhausted trying to quickly care for so many ill patients that only continue to get sicker with time. So why is there minimal effort placed on understanding and addressing known culprits?

Why does the healthcare system continue to only treat the consequences of lifestyle malfunction? It just doesn’t seem to make common sense.

Financial Incentives Versus Patient Well-being

There is no money to be made by the numerous industries driven by having an ill America. Physicians are paid based on how ill patients are, with the complexity of the visit increased when medications are prescribed, test ordered, and procedures performed.

Hospitals are paid to keep all of their beds and facilities full. Pharmacies are paid to sell more drugs. Researchers’ funding is often tied to for-profit companies 100% interested in creating financially profitable products.

With so much effort placed on defining and managing illness, healthcare has convinced us that placing efforts towards prevention is futile and not as effective as the heroic treatment options we are currently utilizing.

Every angle of medicine is financially driven to keep patients ill and only provide short-term, symptom-based treatment.

There is a deep lack of awareness or incentive on how to drive wellness as the focus point of our healthcare system. To do so would require the insurance reimbursement model to completely change.

Reimbursement Tied to Health?

Providers should be valued for their time spent making valuable differences in individual lives versus delivering protocol-style healthcare to manage populations.

Providers should not receive incentives to treat each aliment with medication but instead offer other effective, nonpharmaceutical treatment options. Incentives should be given for practicing the art of clinical medicine versus relying heavily on diagnostic tests and procedures.

Healthcare driven on the foundation of wellness will transform America’s health and overall cost burden.