Tuesday, January 26, 2010

Private Practice is no Picnic

Since my return to Minnesota, I've been working  in a private practice health care organization in a highly managed care environment. I've worked previously in the Veteran's Health Organization (VA) and in a self-pay environment in Washington, DC, but not in this type of organization. It's been fun, invigorating, and challenging. And, it's giving me insight into some of the challenges facing American health care today.

One of the biggest concerns is that reinforcers of behavior are misdirected, guaranteed to induce behavior on the part of clinicians that result in net harm to patients. Here's an example: I tend to spend more time with patients and families, and I am penalized for that. There are other psychiatrists in the community that see patients for 5 mins or less for a medication check. I'm sorry, but I don't understand what can be really assessed in 5 mins. However, if I continue this way, she makes more money than I do. What message does this send? Do we expect doctors to be saints? I can tell you that idealism and professionalism go only so far. A new furnace, private school for the kids, and an occasional vacation for my wife and I are powerful competitors with idealism. 

What do we really want to reward in health care? How much would it take to meet everyone's needs, and if we can't do that how do we decide who gets what?

How do I resolve between my ideals (I've served poor people most of my career) and my personal needs (I have various debts to pay off, the house needs maintenance and we need a new car)?

At the same time, I feel that I am providing a service that people have not experienced before: true professional addiction medicine/psychiatry. Someone who can manage the complex patients, rather than just evaluating them for rehab. I've been surprised by the range and complexity of the patients I've encountered so far. My experience only increases my motivation to change the way we do business. We need to be providing truly professional science-based recommendations and treatment. And by and large, consumers do not have access to that. Rehab services are extremely imporant for those who cannot stabilize at home. In Minnesota, there are more programs than usual who are focused on providing evidence-based treatments such as Suboxone therapy for opioid dependence and pharmacotherapy for alcohol dependence. But what's difficult to access is professional treatment by physicians, the way diabetes, asthma, cancer, hypertension, and depression are treated. My goal is to create a system that will do just that.

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