By Jay Davis
VillageSoup/Waldo County Citizen Senior Reporter
Some look ahead to a single-payer system like those in developed countries around the world. Some look back to when doctors were revered in their communities and care was measured in relationships, not dollars.
Dr. David Loxterkamp, a family physician in Belfast for more than 20 years, looks both ways and finds a “patient-centered medical home,” the modern-day embodiment of values as old as Hippocrates.
Loxterkamp is an articulate man, as befits a doctor whose account of a year in his practice was well-reviewed nearly a decade ago.
On a sunny Saturday recently, he sat among the peonies and irises and clematis outside his Salmond Street home and talked for two-and-a-half hours about what he sees ahead. Parts of that future are as bright as a blossom, but storm clouds are in the picture, too.
When he trained as a family physician 30 years ago, Loxterkamp said he spent almost half his time in hospitals, learning how his patients were treated there. He delivered babies, lots of them, and he considered his relationships with patients an important element of their care.
Today, he said, medicine is dominated by specialists, care is procedure-oriented, and the family physician is disappearing. Indeed, every year since 1998 fewer students have entered med school to become family physicians than the year before.
An evolving practice
Seaport Family Practice, which Loxterkamp started with Dr. Tim Hughes two decades ago, is in the forefront of the movement toward “patient-centered medical homes,” a new design for family doctors. It incorporates new technologies, including electronic medical records and patient-accessible medical charts, and concedes the value of external improvements, such as hospitalists, who treat Seaport patients when they enter the hospital.
Loxterkamp, 55, says he is a primary care physician, which covers internal medicine, pediatrics and family medicine and is sometimes said to include obstetrics and general surgery as well. Only 25 percent of American physicians provide primary care, he said, a reversal of the ratio in other developed countries. And they are the second lowest paid among all classes of doctors, after those in geriatrics.
The finances of family medicine are dictated by large organizations, including the federal government, insurance companies and hospitals.
Loxterkamp said he is only reimbursed for face-to-face encounters with patients, which are viewed as procedures. The considerable time spent referring his patients to specialists, filling prescriptions for medicine, and e-mailing patients, which is part of the doctor-patient communication system at Seaport, are not included.
A patient with a bum knee has several ways to deal with it, Loxterkamp said, from an operation to replace the aching joint to developing a diet and exercise routine to strengthen the surrounding tissue and muscles. The family physician would encourage the second route, but would not be reimbursed for his counsel. The surgeon who installs the new joint, on the other hand, would be paid thousands of dollars.
Family medicine, he said, is usually less expensive than the procedures carried out in hospitals, because doctors are paid based on what they do to patients, not whether they help them. Until the system uses outcomes of medical approaches as the standard for payment, and not procedures, the costs of care will continue to increase, Loxterkamp said.
Seaport Family Practice was one of 36 in the country to participate in the National Demonstration Project, a two-year study to test the validity of a nationwide analysis known as the Future of Family Medicine Report. The report called for adoption of information technology and a strong business model as necessary medicine to cure the ills of family doctors.
Practicing changes
Loxterkamp said Seaport has changed the way it operates in accordance with the report's recommendations. Among the innovations are:
• Filing prescriptions electronically with the mail-order companies most patients choose. “It is much quicker,” he said.
• Working with one nurse as a doctor's partner in the development of a joint note that is placed in the patient's electronic file. The nurse takes the patient's vital signs and the complaint that prompted the visit and enters them in the record, he explained. The nurses and doctors rotate every six months or so.
• Developing what he calls a patient portal, an electronic file that the patient can access from anywhere, reducing the time to transfer medical records and make referrals.
•Hiding nothing from patients, including the recording of information in the record of a visit that might not have been discussed with the patient. “It's absolutely helpful” to have transparent communication with patients, he said.
• Giving patients a role in their health care, which includes clear communication. His notes are not written in “doctorese,” he said, but in words the patient will understand. The communication “gives patients responsibility for their care, which most of them want,” he said.
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