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Primary Care Prevention and the Most Difficult Patients

People say that doctors make the most difficult patients. They’re wrong. My parents make the most difficult patients.

My parents are great case studies for the challenges of primary care and prevention. Years upon years of my attempts reinforcing health education have seen more failures than successes. What can we do to win the primary care and public health battle of prevention?

Recently over dinner with my folks, I asked my dad why he ignores preventive health care recommendations. My dad is a generally healthy senior, and I want to keep him that way as long as possible. So, over and over, I give him the standard line of recommendations: get a colonoscopy (which he’s never done), get a pneumonia vaccine, get a zoster vaccine, get pertussis booster, and reduce those processed grains, amongst others.

I thought for a while that the main barrier was cost. My dad spent many of his pre-Medicare years with just a disaster coverage plan, nothing covering primary care or prevention. I hoped that once he qualified for Medicare with an added supplemental plan we would get him caught up with preventive health services.

A few years later, I’m still 0 for 5 on my recommendations. I thought I would have at least succeeded on the pertussis booster, sold by me as protection for my newborn. But no, still 0 for 5.

The response I got from my dad didn’t make sense to me as a medical provider. He really didn’t think that they (the preventive health recommendations) were really important. “No one” has these diseases (at least no one he knows), so why bother? He was going to die of something eventually, so what’s the point?

Trying to convince him of reducing morbidity and burden of suffering from disease and the prolongation of healthy life have fallen on deaf ears. My dad wasn’t going to listen to his son or his actual doctor who–from what I can gather–mentioned preventive health services in passing without any emphasis.

Every primary care doctor has the same frustrating talk about prevention with patients every day. Folks who we know will ignore all the recommendations and might end up in the ICU with a preventable infection or in the infusion center for chemotherapy with a preventable cancer. The public health and primary care worlds have agreed for decades that preventing disease must be the focus of our health care infrastructure. While we’ve made great strides, we know we have so much work to do.

Below are just a few things that need to change to help in the primary care and public health crusade for prevention. What do you think?

1) Reduce Barriers
Prevention must be the foundation of how society pools its health spending for each other, whether through private or public health “insurance.” But financial barriers such as non-covered preventive services and co-pays/deductibles that are a burden to patients mean that many in our society forego these important procedures and vaccines.

While there are some provisions in the Affordable Care Act that prohibit “cost-sharing” (deductibles, co-pays) for preventive health services such as physical exams, vaccines, and cancer screenings, many health plans are grandfathered in and exempt from these regulations. Additionally, coding/billing issues for both private insurance companies and Medicare produce significant hurdles for patients and their physicians. (Thanks to Robert Bennett of the AAFP for his help understanding the ACA!)

We as a society need a commitment to get rid of ALL financial barriers that might limit people from receiving preventive health services.

Even if cost isn’t a factor for patients, the cost of procuring, maintaining, and handling vaccines is often a burden for many providers. Physicians often pay out of their own pocket for vaccines, and some insurance companies don’t reimburse the full cost of the vaccine, let alone maintenance (refrigeration), expiration/waste, and the staff cost to administer the vaccine.

There are a lot of programs out there for pediatric vaccines that purchase them for doctors (such as the VFC program for lower-income children http://www.cdc.gov/vaccines/programs/vfc/index.html). We as a society need a commitment to vaccinate adults and more programs making it easier for physicians to stock adult vaccines.

2) Pay For Performance?
I’m not a big fan of pay-for-performance (P4P) that would pay physicians and health systems for outcomes. There are a number of arguments against P4P, and I won’t go into them here. But writing this post makes me wonder if there is some value to P4P when it comes to preventive services.

If my dad’s doc were getting incentive bonuses when his patients received preventive vaccines, for example, my dad’s visit might have been different. “Do you want the pneumovax vaccine? I can write a prescription that you take to the pharmacy, then you call to make a nurse visit, and then we’ll administer it. ‘Not really?’ Ok…” might have instead been, “I recommend the pneumonia vaccine, which helps reduce the risk of lung infections that can make you very sick and even kill you. I have it in stock and ready to give, and if you’re ok with it, I’ll have my nurse administer it as soon as we’re done discussing your other issues. ‘Sure, fine?’ Great!”

With outcome-based incentives, primary care docs might be more likely to stock vaccines and make it a quick and easy add-on service, as well as emphasize these and other preventive services if they weren’t already doing so.

3) Marketing
I understand as I write this how naive this sounds, but we as a society have got to stop spending millions in direct-to-consumer pharmaceutical marketing. If those resources were instead spent on marketing life-saving preventive services, maybe folks like my father–after years of hearing the prevention message reinforced–might take these services seriously. I would much rather have my senior patients ask me whether they should be getting a whooping cough vaccine because they heard about it on TV than some drug for some condition that don’t really have.

4) Stories help!
Finally, we need patients to tell their stories if they’re willing to share. The personal stories hit home, such as the patient with colon cancer who wished he had gotten that colonoscopy, or the patient discharged from the ICU last month who wishes she had gotten the pneumonia vaccine. Talk to your patients and see if they’re willing to share their stories at your community or religious centers, health fairs, or other venues.

If my dad heard real people tell their stories, maybe he will start believing that these preventable conditions can truly happen to people like him, and that it’s worth bothering with disease prevention.

Dr. Ravi Grivois-Shah, MD

Dr. Grivois-Shah is a family physician who practices in Tucson, Arizona. He is interested in health policy, health care leadership, population management, and how our primary care work force improves health access and outcomes for our patients and communities. Click on the "about" tab to learn more about Dr. Grivois-Shah. All opinions expressed on this page are solely his own, and does not reflect any employer or organization with which he is affiliated.