An Open Letter To The Nation's Physicians:

There is a war going on in medicine today and physicians are at the center of it. The doctor-patient relationship is under attack. Big guns are loaded to destroy it. My purpose here is not to lament the struggle. Struggles can create stronger entities. My purpose is to insure physicians understand we have a huge gun we have not yet used effectively.

Two years ago an article in TIME magazine picked up this theme of real practice independence and finished with my quote that "now, I feel like a Doctor again." Perhaps how I feel as a Doctor is important, but not nearly so important as how my patients feel. If physicians are going to survive as independent practitioners of the ancient art of healing, and compete effectively with the economic pressures of government, business, managed care, drug industry lobbying, lawyers or whatever the enemy du-jour happens to be, we must focus sharply on one simple objective: controlling our unique resources for the benefit of the patient. Here is how we do it.

For fifteen years I have practiced effective medicine in the HOME of the patient, primarily the elderly and the disabled. These are not housecalls physicians today might relegate to Marcus Welby like aphorisms, including appropriate descriptions as inefficient, unnecessary and unprofitable. These are housecalls made efficient, necessary and profitable by new technologies of the digital age. Here is an example. Last month I saw a 96 year old woman, unable to sit up on her couch because of critical heart failure and severe restrictive lung disease. Using the principle of transthoracic impedance, I measured her cardiac output, ejection fracture and systemic vascular resistance to obtain clear and objective evidence to guide her treatment. Two days later she was walking up a flight of stairs unaided.

This measurement of cardiac function in the home may have been unique, but the technology is thirty years old, well proven and inexpensive to deliver. We have just thought of it only in connection with hospital care. I suspect I may have been the first physician to routinely use portable x-rays developed at home (1985), cardiac enzymes, theophylline and other drug levels with stat chem panels done in a van parked in the patient's driveway (1986), twelve lead EKGs as a routine procedure in the home (1988), measurement of arterial blood gases (1996); and the list goes on. With a current database of over eighty thousand medical calls to the home, our medical group has demonstrated a mature delivery system of quality medicine in the home; a system that replaces the ambulance, most emergency room procedures and much of the current inpatient care in a hospital environment. All this is being done for an average cost of $200.00 per visit for complex patients.

So what!? HCFA reports the nation's doctors increased the number of housecalls to patients by twenty five percent last year thanks, in large part, to the dramatic success of the American Academy of Home Care Physicians in making reimbursement conform to the resource based system required by Congress since 1989. This trend is accelerating with huge repercussions. When physicians can replace the entire overbuilt, overpriced healthcare delivery system in this country with a community based practice which includes the high end capabilities described above; a system which the physicians own and operate, they can achieve pure relationships with their patients without the gatekeeping of profit-motivated entities. Our medical group routinely delivers critical care in the home, complex diagnostic and evaluation procedures as well as the more mundane therapies historically done in hospital environments. We are insulated from managed care since, in the mind of the patients, the value of these quality housecalls far exceed their Medicare assigned price tags. Our doctors are considered heroes by their patients because they offer an alternative to the dreaded 911 call and its subsequent ambulance procedures. Our doctors and nurse practitioners make respectable livings because the patient's home is inherently less expensive than the bricks and mortar overhead of a hospital.

As physicians in this country, we have grown accustomed to physician-owned imaging centers, urgent care centers, outpatient surgical centers and expanded services in our offices; all in our efforts to protect our doctor/patient relationships. But, more and more we are being managed in even these services. We have an opportunity now to take back the practice of medicine and return it to the control of those who understand best that its purpose is to treat patients; not hold down insurance costs. By treating patients in the home non-catastrophic insurance costs become irrelevant and overall cost-containment is endemic to the system.

- C. Gresham Bayne MD