Volume 16, No. 2, Spring 2007
The subject line seemed pretty straight-forward: What do you consider the major health care issues facing Cape Codders?
Members of the Advisory Board of To Your Good Health, A Health Care Newsletter, quickly narrowed this down during their most recent meeting at Cape Cod Community College:
The national pharmacy chain started this program in 2000 and at last count more than 500 of these MinuteClinics were operating in 25 states. They’re open nights and weekends, appointments are not required and the Nurse Practitioners—who have bachelors and master’s degrees—treat your minor illnesses. When they spot something more serious, they’ll suggest a visit to a physician or a hospital emergency room. They do not provide ongoing treatments.
CVS indicated that it will take a few years to get the program of upwards of 100 MinuteClinics running in the Commonwealth and that the Cape was included in their plans.
“That CVS thing will continue to grow,” predicted Steve Abbott, president/CEO of Cape Cod Healthcare, “There will be seven or nine in Boston and they’ll be down on the Cape for sure.”
Mr. Abbott said he wasn’t particularly concerned about the possible conflict of interest with a drug store employee in a position to prescribe medications. “I understand it isn’t so much that their drug business will go up, it’s the pull-through for all the candy and stuff they sell to the people wandering through the aisles while they wait to be seen.”
“That looks like a mixed thing,” said Dr. Arthur Bickford, medical director of Hospice & Palliative Care of Cape Cod, “good for the consumer, but bad for the profession.”
Dr. Herbert Mathewson, former medical director of Cape Cod Hospital and now a trustee of the VNA of Cape Cod Cape and the Rehabilitation Hospital of the Cape and Islands, suggested one added service the CVS program could provide: “If I were writing this bill I would put in a statement requiring CVS to make available to health care providers in their area their pharmaceutical data base,” he said. “That’s because they know more about the medicines I take and how I take them…and if I take them…than my primary care physician. And that information is extremely valuable to the Emergency Room physician or PCP who needs to treat me.”
“Those CVS things are almost inevitable,” conceded Monica Mullin, an aide to Senator Rob O’Leary. “At least they’ll help keep people out of the ERs.”
Why have these mini-clinics staffed by Nurse Practitioners become so popular? After all, CVS is not alone in the field.
It’s because they’re needed.
Dr. Herb Gray, chief of emergency services at Falmouth Hospital, is on the front lines where people go in extremis when they don’t have a regular doctor. “I think it’s important that everyone have health insurance,” he said, “but if you don’t have access to a provider, you can have all the health insurance in the world and it’s not going to give you health care.”
So, how serious is the shortage?
Andrew Young, a former trustee of Cape Cod Hospital, related, “I’ve probably been asked 20 times in the last month, do I know where I can find a primary care physician.”
Denise Dever, president of HomeInstead, a non-medical home care provider, often finds herself in a similar situation. “We’ll often call a doctor for one of our clients and they’ll say if you can’t come into the office, just call an ambulance and go to the emergency room.”
Why the shortage of primary care physicians? The answers involve the demands of that discipline plus basic economics.
“This shortage is really nationwide,” Dr. Gray pointed out, “but here on the Cape there’s an added twist because of our high cost of living.”
“Those doctors who used to hang up a shingle and practice in the community have now become hospitalists [staff doctors] with fixed pay, fixed hours and they actually can get control of their lives,” Mr. Abbott explained. “I can’t imagine who would want to be a primary care physician these days. You’re at the low end of the totem pole in terms of making a living.”
The Cape’s elderly population makes it even tougher, with a patient base that demands more care and with lower Medicare reimbursements footing the bill. “Why would you want to leap into that career?” Mr. Abbott asked.
The Cape’s elderly population adds another unique problem. Because of our age mix, the shortage of gerontologists also is more keenly felt.
Rosemary Dillon’s full title at Cape Cod Community College is Director of Allied Health Services and Gerontology. “On the Cape, family doctors also have to serve as gerontologists, but the care of elders can be very complex and different from primary care. It’s not sexy medicine, but I find it hard to believe we don’t have a Geriatric Assessment Center here on the Cape,” she said, adding with a wry smile, “Maybe we could share one with Florida?”
“Our frail elderly population is the most isolated and vulnerable group of patients,” agreed David W. Rehm, new president/CEO of Hospice & Palliative care of Cape Cod, “and their care is even more under-funded than primary office care.”
The Rehabilitation Hospital of the Cape and Islands has its own staffing problems. “It’s not only in terms of physician recruitment, but also extended to therapists,” reported Carole Stasiowski, RHCI director of communications “Educational reimbursements and (student) loan forgiveness could end up being necessary steps along with signing bonuses because of the competition to attract people.”
And even when patients are back home, but still in need of care, the future is bleak. Rob Fessler, Director of Skilled Nursing Residences for Cape Medical Supply, warned that tightened financing regulations concerning home oxygen supplies and power wheelchairs would be making matters more difficult not only for patients, but for providers as well.
As Dr. Mathewson pointed out, referring to an essay by Dr. Arnold Relman, editor of The New England Journal of Medicine, “He warned about what he called the businessfication of health care, where it’s become less of a profession and more of a business.’ It was written 15 years ago, but it’s more true today than it was then.