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Cardiology Consults; When should the patient return to PCP care

Posted on December 19th, 2012
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As we keep marching forward into this uncertain Obamacare world, we as practitioners and administrators are working to find a path to excellent, evidence-based medical care that is at the same time cost effective. QIP is embarking on an 18-month pilot program to prove that our efforts can result in cost savings and positive health outcomes with our most challenging patients. I honestly believe that we are on the right track and are going to succeed.

No Siver Bullet

It is clear that there will be no silver bullet that solves all the problems. Some of our practice adjustments will help, and some may prove fruitless. What is clear, however, is that we must do something to make changes in the way we use the medical dollar. It is going to take a change in approach and philosophy, starting with the role individual physicians can play in building toward a solution.

Primary care physicians have the closest relationship with patients. In general, patients trust our judgment and often will return to us to validate treatment recommendations from specialists. This is both a great responsibility and a prime opportunity to shape the expectations and the care of our patients. Let’s take the role of primary care physicians in the management of patients with complex disorders, such a cardiovascular disease. I think we all would agree that preventing, diagnosing and treating heart disease drives a large percentage of health care expenditures. So recently, during one of our Patient/Provider Relations meetings, we invited three cardiologists to a round table discussion where we proposed a back-to-the-basics approach to caring for our patients with heart disease. We didn’t want to do it alone, though. By refining our understanding of different philosophies of current cardiology practices and the current literature, we could refine our practice model and maximize its impact on utilization.

What’s our theory?

Well, many of our patients have very stable cardiovascular problems: examples are definitively treated coronary artery disease, uncomplicated congestive heart failure and stable atrial fibrillation. We have created a culture where patients feel they need and have a right to see a specialist if they have ever been diagnosed with such a problem. Is this right? I think, no. I challenge all primary care physicians to reclaim some of these patients. Our patients trust us, and we have a skill set that warrants that trust. If we have a patient that is stable two years out from a bypass or angioplasty, do they need to see a cardiologist? We can prescribe the correct and cost effective medicines. We can see our patients regularly to ensure they are not developing symptoms. We can manage lipids. Very often, our re-vascularized patients receive routine follow up stress tests despite the lack of current symptoms. There is no data to support such utilization. It is our job to use the skill set we have developed to care for our patients in an evidence-based way and at the same time, saving cost to the system. For many patients, it may be a leap of faith to ‘not see their cardiologist’ if that is what they have always done. Let’s take the time to educate these folks. Let them know that if situations or symptoms arise we won’t stand in the way of going back to their cardiologist. We’ll treat them well and we’ll send them back if and when they need to go. So, in our focus group how did our cardiology colleagues feel about this approach?

Across the board, our panel of cardiologists agreed with us. They did not feel threatened by primary care physicians managing routine cardiology problems. They stressed that they know which physicians are providing appropriate care, and are more than comfortable passing the baton to these physicians. The time is right for primary care doctors to take accountability for caring for stable patients with complex illnesses. We can do it. And as a consequence, we’ll be known as an organization that knows our patients, provides the highest quality care and manages our costs second to none.