Can we afford preventive services?
American Journal of Public Health
April 2003
Primary Care: Is There Enough Time for Prevention?
By Kimberly S. H. Yarnall, MD, Kathryn I. Pollak, PhD, Truls Østbye, MD,
PhD, Katrina M. Krause, MA and J. Lloyd Michener, MD
Abstract
Objectives: We sought to determine the amount of time required for a primary care physician to provide recommended preventive services to an average patient panel.
Methods: We used published and estimated times per service to determine the physician time required to provide all services recommended by the US Preventive Services Task Force (USPSTF), at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population.
Results: To fully satisfy the USPSTF recommendations, 1773 hours of a physician's annual time, or 7.4 hours per working day, is needed for the provision of preventive services.
Conclusions: Time constraints limit the ability of physicians to comply with preventive services recommendations.
Discussion (excerpt):
Choosing the best available services is a laudable goal in light of the time pressures faced by physicians. It would be preferable, however, to pursue solutions that do not require clinicians to abandon applicable and effective services. Alternatives that extend beyond the current model of face-to-face patient care, such as group visits with physicians and nurses, use of health educators or dietitians for counseling, and various forms of patient education through telephone or print or electronic media, should be explored further.
It has also been suggested that physicians and nonphysician clinicians should work together, providing illness care and wellness care, respectively. This is perhaps the most promising model currently available, especially because the number of nurse practitioners and physician assistants is expected to increase. This form of practice will require new relationships among physicians, nurse practitioners, and physician assistants that build on their complementary strengths. Delivery of services through other health care professionals or new media will require changes in the current method of reimbursement for preventive services, as well as further research to develop strategies for organizing such delivery.
Currently recommended preventive services for the US population require an unreasonable amount of physician time. The magnitude of the problem is likely to increase as new genetic tests become available. Our current system of preventive care delivery-provided by physicians seeing patients for acute visits and for periodic preventive health evaluations-no longer meets national needs. New methods of preventive care delivery are required, as well as a clearer focus on which services can be best provided, and by whom.
http://www.ajph.org/cgi/content/abstract/93/4/635
Comment: There is no argument about the benefit of evidence-based preventive services and that they should be included in any system of healthy care delivery. There is some dispute about the cost of such services. A frequent claim is that such services reduce costs by preventing more costly medical problems. Considering the tremendous amount of resources that would have to be devoted to this effort brings into question whether cost savings can be achieved, especially when you consider that preventing some disorders will not prevent individuals from eventually developing other costly pathological conditions. Nevertheless, the benefit of prevention in maintaining a better quality of life makes it imperative that we should pursue methods of providing access to proven preventive services.
It is quite clear that our current system has been incapable of meeting this challenge, and, as structured, will never find enough resources to fund these services, not when we continue with policies that prioritize funding administrative waste over "unnecessary" preventive services.
It is impossible for primary care physicians to devote over seven hours a day to preventive services. But a single, integrated system, funded with a global budget, could allocate resources specifically to these services. It is also clear that these services could be delivered at a lower cost if we changed from primary physician micromanagement of the preventive services to "specialists" in this field. Such specialists might include nurse practitioners, physician assistants, or even a new category of prevention professionals, working within the integrated health care team. Establishing streamlined protocols that could efficiently process large numbers of individuals, supervised by individuals specifically trained in preventive services, could greatly expand access to these beneficial services in a much more cost-effective manner.
This is yet one more reason to abandon our inefficient, fragmented system of funding health care and adopt a single publicly-administered program of health care coverage.