A market for family practitioners.

Abstract

'The key will be in the drawer of the pink table on the porch'. Mary-Beth, our landlady, faxed a message explaining how we should make our way to her house, which was to be our home for the next two weeks. These instructions did not quite fit our image of a crime-ridden America but our expectations were challenged on many occasions during our stay. There were three of us, Richard from Glasgow, Domhnall from Belfast, both general practitioners, and Keith an NHS executive from Lincolnshire. With our base at Tufts University, we were to spend two weeks travelling to various academic departments, hospitals, laboratories and practices in Boston and other parts of New England, looking at the system. Our programme was co-ordinated by Dr Bill Reichel at Tufts University Medical School. In the USA, health care is a patchwork of insurance plans, each with its own contract regulations and payment scheme. The more money your employer is prepared to pay for your insurance, the better the service provision. Driven by the financial interests of these insurance plans, there is huge pressure to reduce costs, especially in reducing the length of hospital stay, with very close monitoring. One patient had recently undergone transurethral resection of the prostate. The operation was performed on a Monday with discharge on Wednesday, but the insurance company telephoned his urologist to ask why he had been in hospital so long. They suggested that he could have been discharged as a day case, with removal of the catheter as an outpatient. Hospitals themselves manage patients according to detailed guidelines or protocols, so that, for example, a patient with an uncomplicated myocardial infarction will go through a planned programme of care with each aspect of care scheduled at a specific time. This may be criticized as health care by recipe book, but if the patient knows exactly what is expected on each day and at each stage of admission it is unlikely that any particular aspect will be overlooked. For scheduled admissions patients discuss their treatment plan before they go into hospital, and make the necessary arrangements for discharge in advance. The Tufts University Medical School is linked directly to the neighbouring hospital, the New England Medical Center. While we were in Boston the future of this hospital was discussed in the newspapers every day. Weighed down by huge debt, it was in danger of closing, and was negotiating with one of the insurance plans for a merger. Each day the arguments raged, but it seems that no hospital is entirely safe in Boston because the city has such an oversupply of beds. In direct contrast to the pressure on hospitals and specialists there are increasing opportunities for family physicians because the health maintenance organizations (HMOs) see them as an opportunity to save money through their primary care and gatekeeper role. This is a doubleedged sword. Although the demand for family doctors exceeds supply, the HMOs exert considerable pressure with restricted formularies and many constraints on referral. Family doctors work in various ways-as salaried employees of the HMO, in freestanding partnerships, or singlehanded in private practice. Those working independently, either in partnership or single-handed, care for patients who subscribe to a variety of insurance plans. This, however, does not give them clinical autonomy since each insurance plan restricts a doctor to a limited list of consultants and a limited formulation of drugs. These lists differ between plans, which makes for a bureaucratic nightmare. Doctors may also be audited by these insurance plans, which regularly examine their records to ensure that all the appropriate investigations and preventive medicine checks have been done. Family doctors write extensive records, since they must have written evidence that all those procedures likely to be audited have been completed. There is also the fear of litigation. It is not surprising, therefore, that a consultation may take, on average, 30 min. On a more positive note, the income is good and the gap between specialists and generalists has narrowed greatly. In private practice, income depends on workload, and those employed by a HMO also have a good income ($120-150k) with many incentives. Residents (the equivalent of a GP registrar) will have numerous offers of employment in their final year; medical students often run up a sizeable debt at medical school, and the HMO may be prepared to write this off as an incentive for those finishing residency. On the other hand, these employers work doctors hard and expect them to take on a high patient load. With a general undersupply of family doctors, there is a great shortage in some regions. In Lowell, just 20 miles 0