Rants & Ruminations on Ethics & Disability
Rants & Ruminations on Ethics & Disability
Primary Care for People with Disabilities and Complex Health Conditions
Children with disabilities and complex health care conditions often face difficulties finding coordinated and continuing primary health care. Adults with disabilities and complex health care conditions typically face much more sever challenges in accessing primary care. These difficulties appear to be endemic to most of not all developed countries although they appear to play out somewhat differently in socialized health care than for-profit systems.
The transition from pediatric to adult services is particularly difficult. Adults with complex health conditions need continuity of care even more than other patients, because the the health-care provider needs expertise in the whole patient before treatment. Several factors contribute to these difficulties.
Sir William Osler is credited with the axiom, “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” It is as true today as it was 100 years ago, and it is true wether or not a patient has a complex health condition or not . But when a patient has a complex health condition, there is a great deal that the doctor has to learn about the individual before he or she can provide quality care. When the patient arrives with a six-inch thick file, most physicians are reluctant to invest the time required to learn what they need to know about the patient. When the patient arrives without the thick file that should be with them, Doctors are also reluctant to get involved.
The simple fact that our physicians are paid according to the procedures they complete also creates disincentives to want to work with patients that require much more time for the same procedures. In some cases, this gets even more complicated when hospitals and health boards get involved. For example, peer reviews sometimes evaluate doctors on how long their patients remain in hospitals for given conditions or procedures. Patients with complex health care conditions generally have longer hospital stays and complications. As a result physicians may be seen as less competent or less productive simply because they serve more challenging patients.
Another obstacle is that special facilities or equipment may be required to provide the same services. For example, many people with paralysis or mobility impairments are unable to get on an examining table, many examination rooms are too small to accommodate wheelchairs, and many practices have no facilities to weigh people who cannot stand on a scales. The cost of making every doctor’s office fully accessible to every patient would be significant, but the failure to make all facilities accessible perpetuates discrimination and lack of access.
These are just a few of the problems. There are no doubt many others and ATTITUDE is a big one. It is time for us to seriously begin to address potential solutions. Here are a few.
Establish primary care networks and require that every network has the capacity to serve patients with complex health care needs in their geographical area.
Issue grants to primary health-care providers for equipment required to betters serve underserved populations.
Train nurse clinicians as health care coordinators for patients with complex health care needs. Their job is to prepare and organize relevant information for the primary healthcare provider to make care more manageable.
Provide financial incentives for serving patients with complex health care needs. For example, attach a 15% addition to each procedure performed if it is performed on patients identified as having complex healthcare needs.
The costs of such initiatives may be significant, but they may be offset by the savings produced by serving people in primary care settings rather than responding to their lack of good primary care with much more expensive hospital-based services. - Dick Sobsey
Monday, December 3, 2007