Primary Care

Virtually all experts say successful health-care reform should include a coordinated system with a balanced physician mix. And that means at least half of the doctors should be primary-care physicians - family physicians, general medicine internists, general pediatricians. This estimate is based on data from countries with less expensive and better organized systems than ours (Canada, Great Britain, Germany) and on successful Health Maintenance Organization models in the United States.

An interesting factoid entered the health-care debate this past week. It was this: Though cost-cutting is all the rage, the great majority of fourth-year medical students are still headed for careers as high-priced specialists, which in turn drives up the cost of medical care. It also means there's a shortage of primary-care physicians - or so-called generalists. Nowadays, a third of U. S. doctors are generalists; Congress is looking at ways to get the number up to half. So, what would change the students' minds, and nudge them back to the front lines of medicine, the better to dispense ounces of prevention rather than pounds of cure?

Like millions of Americans, Sandy Johnson is looking for the right doctor. But Johnson's search is a little more complicated than most. The 48-year-old Gloucester Township resident has lupus and belongs to an HMO. For 10 years, Johnson says she has struggled with managed care rules limiting referrals to specialists with the experience to treat her immune disorder. Her family doctors have insisted they could take care of her. Johnson is just as insistent they don't have the training or expertise her condition demands.

On the contentious issue of access to obstetricians and gynecologists, the Senate's managed-care reform bill offers a right that is essentially moot for most women. They already have more access to ob-gyns than the bill would assure. The Republican-devised bill, which passed the Senate on Thursday, would let pregnant women in federally regulated health plans go directly to obstetricians without first getting permission slips from their primary-care doctors. But women could not go directly to gynecologists except for "routine" care - which could be limited to one annual visit.

When the search committee for West Jersey Health System hunted last year to fill the hospital's vacant spot of president and chief executive officer, it looked for someone who could meet three major criteria: work with less funding, diversify into other lines of business such as nursing homes, and find ways to work with the managed-care industry. Rich Miller, who has spent the last nine years at West Jersey - most recently as interim president and CEO - said he could do the job. And the search committee, ruling out three other highly considered applicants from across the country, said the same.

Much of the discussion about the health-care reform legislation just signed into law has focused on the uninsured and the problems of private insurance. But what about a large group of Americans who face none of these issues - namely, those covered by Medicare? While much of the reform will not impact them, there are three areas in which older adults definitely will be affected: prescription drug coverage, managed care, and access to primary-care providers. The impact on those facets of their health care is likely to be good, bad, and potentially ugly.

A week ago I received an education concerning a part of the medical care system known as the Health Maintenance Organization (HMO) of New Jersey that proved to be quite an eye opener. What made the whole thing important is that others must also be frustrated by the same inadequate and ineffective treatment. I related the details of my experience in last Saturday's column, explaining how the system failed, first because I happened to be faced with a serious eye problem on the previous Wednesday, the traditional day off for most doctors.

A local congresswoman, six hospital executives, and another dozen area health professionals rallied at City Hall yesterday to push hard for health-care reform, reaching a critical stage now in Washington. "We're at a moment that is potentially transformative," said Rep. Allyson Y. Schwartz, a Democrat representing parts of Philadelphia and Montgomery Counties in Congress. "I think there are real challenges ahead. It's not about being pessimistic or optimistic. It's about getting this done.

After a year, the first 32 medical practices to sign up for the Rendell administration's chronic-care initiative reported that their diabetic patients were doing better. Forty-four percent of the 15,000 diabetic patients in the program gained ideal control of their blood sugar, up from 33 percent a year ago. Participants say the program works because it gives incentives for caregivers to track patients better and to hire more staff. Over time, proponents hope to see broad health improvements and big savings from fewer hospitalizations and ER visits.

Emily Duffy, a licensed social worker, was walking down the hall of her North Philadelphia clinic last month when she heard crying in Exam Room 3. She opened the door and met Patricia Stone, 26, and her children ages 5, 3, and 2. What happened next illustrates a paradigm shift in mental health care - seamlessly integrating what is known as behavioral health into a primary practice - that is gaining traction nationwide. While the children underwent routine physicals, Duffy learned that the 3-year-old's father had died violently three weeks earlier.

New Jerseyans who live in different communities use hospitals at widely different rates, and those differences could pave the way to improving health care and reducing costs, according to a new report by Rutgers University researchers. The report, focused on use patterns in low-income communities and opportunities for better care and lower costs, found wide variations in how many avoidable ER visits residents make. The reason that this information is so valuable, according to coauthor Joel Cantor, director of the Rutgers Center for State Health Policy, is that it opens up the possibility that communities that rely heavily on hospitals for primary care can learn from those who make fewer trips to the ER. For example, the report found that Camden residents had more than three times as many avoidable visits to emergency departments than did residents of the Union City-West New York-North Bergen region.

The new Karabots Pediatric Care Center in West Philadelphia, with 35 doctors, is by far the biggest primary-care office in the Children's Hospital of Philadelphia network. But the $27 million facility at 48th and Market Streets, named for Nicholas and Athena Karabots, who contributed $7.5 million toward the project, aims to be much more than a doctor's office with 56 examination rooms. The Karabots Center opened in phases last month, combining three West Philadelphia sites. The official ribbon-cutting is scheduled for Wednesday.

In the Region Regional unemployment ticks down Philadelphia-region unemployment in October was 8.3 percent, down from 8.4 percent in September and unchanged from a year earlier, the U.S. Department of Labor said. The figures for the 10-county area defined by the department are not seasonally adjusted. Nationally, rates fell in 201 metro areas, rose in 116, and were unchanged in 55. The department reported earlier that the seasonally adjusted national unemployment rate ticked up to 7.9 percent in October from 7.8 percent in September.

A couple of years ago, when Jasir Huff, now 6, suffered a concussion, all his mother was told to do was give him some ibuprofen and keep an eye on him. When Jasir's big brother, Jordan Goins, 12, fell and struck his head on the concrete basketball court at his school in September, it was a whole new ball game. Jordan's pediatrician, who is part of Children's Hospital of Philadelphia's primary care network, ordered "cognitive rest" for his concussion. That meant no school, no homework, no computer, no texting, and no video games.

Nine primary care physicians' practices in South Jersey are participating in an initiative that will pay them an average of $20 month per Medicare fee-for-service beneficiary to support enhanced, coordinated services, the federal government's Center for Medicare and Medicaid Innovation said. The goal is to improve quality and reduce costs. Overall, 73 primary care locations in New Jersey were selected to participate in the program, which is being launched this fall in seven regions around the country.

Support for restaurant owner Why is the owner of Chick-fil-A being persecuted for his religious beliefs ("Chick-fil-A fans jam restaurants in ‘appreciation,'" Thursday)? I disagree with him wholeheartedly, but that is no reason to persecute him. His company puts out a good product, it has cheerful and helpful employees, and is also closed on Sundays because of the owner's beliefs. The way the world is today, it is refreshing to see someone stand up for his beliefs. So, while I disagree with his beliefs, I will continue to patronize his establishments.

Well, now. So how's that hope and change thing working for us? I'd say, after Thursday, pretty darn good. The Supreme Court's 5-4 decision to uphold President Obama's besieged signature legislation - the Affordable Care Act - constitutionally validated the law that cleared the path for providing universal health care for everyone. Which should be as American as apple pie. You'd think. Yet since the historic law passed two years ago, conservatives have spit out "Obamacare" as if the very word were arsenic.

CHICAGO - Mary Lou Rothman has her doctor's e-mail and cell phone number, with permission to call day or night. When she recently came down with a stomachache, she called the office and got an appointment within three hours. When the stomachache turned out to be appendicitis, her doctor, Marcy Zwelling, went to the hospital with her and stayed by her side through two surgeries, the second brought on by excessive bleeding. Only after 2 a.m., when it was clear the second surgery had been successful, did Zwelling go home.

A health coalition in Camden won a $3.45 million grant Thursday to strengthen diabetes care in a city where rates far exceed the national average, adding to medical costs and detracting from residents' quality of life. The grant, from the Bristol-Myers Squibb Foundation, is intended to enhance and deepen a three-year-old, citywide diabetes collaborative, officials said at an evening meeting. Most of the money will go to two or three primary-care practices, expected to be chosen next month.

Nearly a decade ago, with the deadly implications of America's obesity epidemic first sinking in, medical guidelines recommended that providers screen all adult patients and offer weight-loss help to those that need it. But with few proven techniques for family physicians to use, no training, and no insurance reimbursement, the guidance is often ignored. Now two new studies - one from the University of Pennsylvania, the other from Johns Hopkins - offer some of the first evidence of success with weight-loss programs that the authors said would be relatively easy for primary care providers to put into practice.