A Primary Physician
a u t h o r B I O G R A P H Y
PREAMBLE
“The electric light did not come
from the continuous improvement of candles.”
Oren Harari ( 1949 – 2010 )
^
“To know that I am nothing, that is wisdom;
to know that I am everything, that is love;
and in between these two, life moves.”
North African proverb
4 Pages — 1 —
EDUCATION
Two small towns sequentially located in western Iowa and eastern Nebraska formed the beginnings of my life. I finished High School in 1960 and attended Grinnell College as an undergraduate. Medical school began at the University of Nebraska Medical Center in 1963 and ended in 1969. Except for a year as a straight medicine, first-year resident at Harlem Hospital in New York City (1969-70) and a first-year pediatric residency at the University of Minnesota (1970-71), all of my training was at the University of Nebraska Medical Center. This included two years in graduate school for a Master of Science degree in Physiology and Pharmacology (1965-67) and two years as a post-graduate Pediatric Resident (1971-73). Having finished my post-graduate training, I served a military obligation for the Army from 1973 to 1975. During the second year in the Army, I was Chief of the Amosist Training Section, Health Science Academy, Fort Sam Houston in San Antonio. The military experience convinced me of the great potential for change represented by precisely focused training systems.
PRIMARY PHYSICIAN
My own professional participation in the fabric of health care began in 1975 as a Primary Physician near the northwest edge of Omaha. With population growth during the 41 succeding years, our small group-practice became centrally located. Closing in 2016, I had shared a small private practice with two other physicians and one nurse practitioner. With varying degrees of work commitment, we represented the equivalent of 2 full-time equivalent physicians. Our clinic offered Primary Healthcare to approximately 2,300 people as defined by each person having been seen at least once in the last 18 months. The panel included approximately 850 Medicare-eligible persons. We continued to be independent and especially appreciated the opportunity to manage our own work environment. It was a privilege to have had so many generational patient relationships when my original associate and I retired together on 10-31-2016 by closing the clinic.
OTHER PROFESSIONAL EXPERIENCE
During my professional career, I have assisted several healthcare institutions with the development of medication formularies. For each institution, I served as the Chairman, or acting Chairman, of their Formulary Committee. In 1985, my first experience with Formulary development was for a traditional gatekeeper, risk-sharing HMO. Subsequently, I have initiated formulary development for a pediatric hospital, another HMO (non-risk sharing) and beginning in 1993, Immanuel Medical Center that eventually became part a regional health system encompassing 15 acute care hospitals and a University Hospital.
GATE – KEEPER HMO EXPERIENCE
From 1977 until 2000, our practice employed a clinical pharmacist as a member of the office staff with a small dispensing pharmacy. The ability to integrate a clinical pharmacist into the direct process of healthcare was the most professionally satisfying time of my career. By 2000, most health insurance companies had begun to use a Pharmacy Benefits Manager. As a result, we were economically forced to close the office pharmacy. Starting in 1990, we employed R.N. level nurses for all of our clinical support staff. During the HMO risk-sharing years of 1990-97, the combined support staff of these nurses and the clinical pharmacist helped our clinic accomplish significant control of the HMO risk-sharing obligation.
During the HMO years, our hospitalization rate for employer-based plans averaged 230 days/1000 members while the plan average was about 350 days. For the Medicare Advantage patients, our annual hospitalization rate averaged 2200 days, and the plan rate averaged 3500 days. The plan, Share Health Plan of Nebraska (eventually purchased by United Healthcare), periodically would assess our performance for anomalies in the quality of their member’s health care. Typical of these assessments were member turnover and member complaint rates. My understanding from the Plan was that these assessments indicated no deficiencies of health care nor any patient selection anomalies.
It is my opinion that the improved level of financial efficiency during our HMO experience occurred as a result of two factors. First, there was a substantially improved efficiency from the medical TRIAGE performed by the R.N. level nurses at the point of initial phone contact with patients. Second, there was a baseline management process, in place for every patient, to define a comprehensive care plan for any person with Complex Healthcare Needs. This emphasis on monitoring a care plan was augmented by the presence of a clinical pharmacist with our own dispensing pharmacy. The underlying theme was always: ‘Are we doing what we’re doing for the right reason?’ It is still amazing to me that 80% of medication needs could be accommodated by stocking just 125 products. It was occasionally frustrating but always gratifying to achieve a continuing level of justly efficient as well as dependably effective healthcare, the rate-limiting process being the availability of and the accessibility to enhanced Primary Healthcare.
COMMENT
My experience with the operational issues during the risk-sharing HMO days is a significant source of my personal commitment to the benefits of efficacious Primary Healthcare. It has much to offer our nation’s healthcare industry for improving the efficiency of healthcare’s responsibility for resource allocation. During my eventual 41 years as a Primary Physician, it has been my privilege to participate in an incredible improvement of the technology for healthcare. The changes in medication strategies, immunization prevention (from 7 to now 23 separate infections), imaging, and endoscopy would have been unimaginable in 1975. It is my view that our healthcare costs are excessive because our healthcare industry does not have the institutional capacity to manage the complexity represented by these advancements, responsively for each citizen. A special, collective action strategy will be required for any reform of our nation’s healthcare institutions, community by community. Without institutional change at this level of complexity, increased funding for our nation’s healthcare of the uninsured is likely to produce paradoxical results.
National Health represents a concept for resolving the low-level of efficiency by our nation’s healthcare. It is not only focused on Primary Healthcare for each resident person. It is also focused on the context of this healthcare. Day by day, every Primary Physician encounters the obligations created by the daily exposure to a very high-level of uncertainty associated with contemporary HEALTH. To withstand these obligations, the physician’s entire professional career should encounter collaboration, transparency, and trust. — 3 —
Promoting this experience daily for each Primary Physician would represent the most important strategy for ensuring that each resident person also experiences collaboration, transparency, and trust during an encounter with any physician. Ultimately, high-value healthcare is based on the attributes of a caring relationship. The economic circumstances for healthcare are very important but are not the ultimate determinant for the quality of this healthcare. Ultimately, the efficiency and effectiveness of healthcare are related to the caring relationship between each person and their Primary Healthcare Team, especially its Primary Physician. Promoting this relationship should be the overriding concern of every healthcare institution, day by day.
Empathy is the preeminent human attribute for a caring relationship. Its spontaneous expression, day in and day out, is also the most difficult attribute to achieve during the healthcare of each resident person. And, every person’s Stable HEALTH is ultimately dependent on it.
Paul Nelson
Omaha
January 2021