Michael J. Pontious, MD

The burden of giving a diagnosis to patients who have no discernible clinical findings is often frustrating and anxiety provoking for the primary care clinician. This frustration is magnified when that patient returns on a frequent basis. These patients have been called the worried well, but there is no good CPT code for this diagnosis.

Smith et al¹ have taken a novel approach to evaluating patients who are frequent users of primary care services. In this preliminary report they develop a classification process that helps define the distinction between somatization disorder and the “worried well.” In the process, they give the reader a longitudinal look at this group of patients.

There is a poor fit between the frequent user and the existing nomenclature. One of the striking findings by Smith and colleagues was that only a minority of the patients who presented for frequent care actually fit the definition of somatization disorder when studied over the 3-year period. Furthermore, the authors point out that there has been very little study about this phenomenon. Although every practice deals with these visits in its own way, little has been done to describe or to quantify this group of patients. Much less has been done to assist with clinical interventions.

The authors put forward a nomenclature for the worried well, showing that 14% of frequent users without physical findings had somatization disorder at baseline, 35% had an organic disease, and 51% had a minor acute illness. The authors watched health care use by these cohorts over 3 years and found that more than half of the patients initially defined as having somatization disorder were reclassified to the minor acute illness class within the next 2 years. There is a persistence of high utilization in 17% of the minor acute patients and 33% of the somatizing patients. For the clinician, these 2 groups often present clinical dilemmas in terms of understanding how to care for them and what resources to use in their care.

More questions and the search for answers

This preliminary study presents many clinically relevant issues. Although the patients studied were members of a health maintenance organization (HMO) in Michigan, the frequency of this problem in non-HMO practice is significant. Is there greater use of the system by patients who choose an HMO model of health care delivery? It might also be of interest to see if the frequent use was physician dependent. Many clinical practices have very little trouble with frequent users, while others are overwhelmed by the problem. Is there something in the style or arrangement of the practice that fuels frequent use? In the non-HMO model, these patients are at risk of obtaining care from multiple health care providers.

The problem of how to treat frequent users of the health care system is common in primary care. Management strategies have been poorly documented, and the diagnosis of these patients is extremely frustrating for primary care clinicians. It is clear that further research is required. Practice-based research networks can quantify the problem of the patients with minor acute illness and determine which intervention strategies will be effective. This study is an important start down that road.

The burden of giving a diagnosis to patients who have no discernible clinical findings is often frustrating and anxiety provoking for the primary care clinician. This frustration is magnified when that patient returns on a frequent basis. These patients have been called the worried well, but there is no good CPT code for this diagnosis.

Smith et al¹ have taken a novel approach to evaluating patients who are frequent users of primary care services. In this preliminary report they develop a classification process that helps define the distinction between somatization disorder and the “worried well.” In the process, they give the reader a longitudinal look at this group of patients.

There is a poor fit between the frequent user and the existing nomenclature. One of the striking findings by Smith and colleagues was that only a minority of the patients who presented for frequent care actually fit the definition of somatization disorder when studied over the 3-year period. Furthermore, the authors point out that there has been very little study about this phenomenon. Although every practice deals with these visits in its own way, little has been done to describe or to quantify this group of patients. Much less has been done to assist with clinical interventions.

The authors put forward a nomenclature for the worried well, showing that 14% of frequent users without physical findings had somatization disorder at baseline, 35% had an organic disease, and 51% had a minor acute illness. The authors watched health care use by these cohorts over 3 years and found that more than half of the patients initially defined as having somatization disorder were reclassified to the minor acute illness class within the next 2 years. There is a persistence of high utilization in 17% of the minor acute patients and 33% of the somatizing patients. For the clinician, these 2 groups often present clinical dilemmas in terms of understanding how to care for them and what resources to use in their care.

More questions and the search for answers

This preliminary study presents many clinically relevant issues. Although the patients studied were members of a health maintenance organization (HMO) in Michigan, the frequency of this problem in non-HMO practice is significant. Is there greater use of the system by patients who choose an HMO model of health care delivery? It might also be of interest to see if the frequent use was physician dependent. Many clinical practices have very little trouble with frequent users, while others are overwhelmed by the problem. Is there something in the style or arrangement of the practice that fuels frequent use? In the non-HMO model, these patients are at risk of obtaining care from multiple health care providers.

The problem of how to treat frequent users of the health care system is common in primary care. Management strategies have been poorly documented, and the diagnosis of these patients is extremely frustrating for primary care clinicians. It is clear that further research is required. Practice-based research networks can quantify the problem of the patients with minor acute illness and determine which intervention strategies will be effective. This study is an important start down that road.

The burden of giving a diagnosis to patients who have no discernible clinical findings is often frustrating and anxiety provoking for the primary care clinician. This frustration is magnified when that patient returns on a frequent basis. These patients have been called the worried well, but there is no good CPT code for this diagnosis.

Smith et al¹ have taken a novel approach to evaluating patients who are frequent users of primary care services. In this preliminary report they develop a classification process that helps define the distinction between somatization disorder and the “worried well.” In the process, they give the reader a longitudinal look at this group of patients.

There is a poor fit between the frequent user and the existing nomenclature. One of the striking findings by Smith and colleagues was that only a minority of the patients who presented for frequent care actually fit the definition of somatization disorder when studied over the 3-year period. Furthermore, the authors point out that there has been very little study about this phenomenon. Although every practice deals with these visits in its own way, little has been done to describe or to quantify this group of patients. Much less has been done to assist with clinical interventions.

The authors put forward a nomenclature for the worried well, showing that 14% of frequent users without physical findings had somatization disorder at baseline, 35% had an organic disease, and 51% had a minor acute illness. The authors watched health care use by these cohorts over 3 years and found that more than half of the patients initially defined as having somatization disorder were reclassified to the minor acute illness class within the next 2 years. There is a persistence of high utilization in 17% of the minor acute patients and 33% of the somatizing patients. For the clinician, these 2 groups often present clinical dilemmas in terms of understanding how to care for them and what resources to use in their care.

More questions and the search for answers

This preliminary study presents many clinically relevant issues. Although the patients studied were members of a health maintenance organization (HMO) in Michigan, the frequency of this problem in non-HMO practice is significant. Is there greater use of the system by patients who choose an HMO model of health care delivery? It might also be of interest to see if the frequent use was physician dependent. Many clinical practices have very little trouble with frequent users, while others are overwhelmed by the problem. Is there something in the style or arrangement of the practice that fuels frequent use? In the non-HMO model, these patients are at risk of obtaining care from multiple health care providers.

The problem of how to treat frequent users of the health care system is common in primary care. Management strategies have been poorly documented, and the diagnosis of these patients is extremely frustrating for primary care clinicians. It is clear that further research is required. Practice-based research networks can quantify the problem of the patients with minor acute illness and determine which intervention strategies will be effective. This study is an important start down that road.

Most physicians will nod their heads in agreement as they read “Physician Satisfaction with Medicaid Managed Care: The Missouri Experience” by Gazewood and colleagues (J Fam Pract 2000; 49:20-26). The results from that article concur with our feelings about caring for patients with Medicaid coverage. It is a frustration that is common among family physicians.

As with any study that coincides with our prejudice, physicians will be pleased to see that someone has done the research necessary to provide data. This data can then be quoted to those who manage managed Medicaid programs as proof that there are problems. The bullets on an executive summary of the results would look something like this:

• Medicaid continues to be a frustrating endeavor for many physicians in primary care.
• Physicians in Missouri are dissatisfied with Medicaid managed care in comparison with fee-for-service Medicaid and commercial managed care.

Gazewood and coworkers sense that autonomy in making clinical choices is the critical issue for determining whether a clinician will be satisfied with the Medicaid revolution that is sweeping the country. Their study gives lesser weight to the role of equitable compensation for the provision of health care services. They argue that it might be necessary for the designers of Medicaid managed care to incorporate physician autonomy into the formula for success.

Autonomy and compensation

I have difficulty separating autonomy and compensation. In some ways they are so intertwined that discussing them separately seems shortsighted. Autonomy in making clinical choices is limited by rapidly disappearing specialty clinicians, who choose not to participate in Medicaid because of low compensation rates for their services. In many primary care practices this has accelerated to a crisis issue. For example, in my community there are delays of several weeks to have children seen by neurologists, since there are only 2 in the state who will evaluate Medicaid patients.

As a family physician, I am taking increasingly greater risks in the care of my Medicaid patients, because I can rarely find local assistance in the specialty ranks. The delays prevalent in the specialty care provided 100 miles away by waiting list only has taught me much about compromise and marginal quality care.

I have such autonomy at this level of care that it frightens me.

This crisis is not simply a specialist/generalist issue; family practice as a discipline must also bear a sizable portion of the blame. We now have a number of family physicians in residency training who consistently stay away from any Medicaid contract, as they begin their practice. Is this because of the frustration that family practice residents endure while caring for this group of patients during their training? Is it because of an attitude taught by frustrated faculty?

Whether a residency program practice, with its legions of seemingly ungrateful Medicaid patients, or the specialist preceptors who will not provide care or consultation are to blame is unknown. But I am concerned that we may be creating a catastrophic trend. Many of our most talented residents are not the least bit anxious about making the decision not to include Medicaid in their insurance panels when starting practice. Will the next generation of clinicians be prepared or motivated to care for the poor and disabled?

Somehow as clinical teachers we have failed; somehow we have not been able to mentor and explain one of the traditions of our profession and specialty. The findings of Gazewood and colleagues are not limited to Missouri. They seem to permeate the spectrum of primary care.

Autonomy may make clinicians more satisfied, but the problem is much more sinister and perverse. It is no longer politically correct for those of us in primary care to shake our fingers at our specialist colleagues and accuse them of “cherry picking” or taking the “cream off the top,” since these phenomena are now also firmly entrenched in primary care.

I am not confident that autonomy in clinical decision making is going to change this. The circle has been broken.

Most physicians will nod their heads in agreement as they read “Physician Satisfaction with Medicaid Managed Care: The Missouri Experience” by Gazewood and colleagues (J Fam Pract 2000; 49:20-26). The results from that article concur with our feelings about caring for patients with Medicaid coverage. It is a frustration that is common among family physicians.

As with any study that coincides with our prejudice, physicians will be pleased to see that someone has done the research necessary to provide data. This data can then be quoted to those who manage managed Medicaid programs as proof that there are problems. The bullets on an executive summary of the results would look something like this:

• Medicaid continues to be a frustrating endeavor for many physicians in primary care.
• Physicians in Missouri are dissatisfied with Medicaid managed care in comparison with fee-for-service Medicaid and commercial managed care.

Gazewood and coworkers sense that autonomy in making clinical choices is the critical issue for determining whether a clinician will be satisfied with the Medicaid revolution that is sweeping the country. Their study gives lesser weight to the role of equitable compensation for the provision of health care services. They argue that it might be necessary for the designers of Medicaid managed care to incorporate physician autonomy into the formula for success.

Autonomy and compensation

I have difficulty separating autonomy and compensation. In some ways they are so intertwined that discussing them separately seems shortsighted. Autonomy in making clinical choices is limited by rapidly disappearing specialty clinicians, who choose not to participate in Medicaid because of low compensation rates for their services. In many primary care practices this has accelerated to a crisis issue. For example, in my community there are delays of several weeks to have children seen by neurologists, since there are only 2 in the state who will evaluate Medicaid patients.

As a family physician, I am taking increasingly greater risks in the care of my Medicaid patients, because I can rarely find local assistance in the specialty ranks. The delays prevalent in the specialty care provided 100 miles away by waiting list only has taught me much about compromise and marginal quality care.

I have such autonomy at this level of care that it frightens me.

This crisis is not simply a specialist/generalist issue; family practice as a discipline must also bear a sizable portion of the blame. We now have a number of family physicians in residency training who consistently stay away from any Medicaid contract, as they begin their practice. Is this because of the frustration that family practice residents endure while caring for this group of patients during their training? Is it because of an attitude taught by frustrated faculty?

Whether a residency program practice, with its legions of seemingly ungrateful Medicaid patients, or the specialist preceptors who will not provide care or consultation are to blame is unknown. But I am concerned that we may be creating a catastrophic trend. Many of our most talented residents are not the least bit anxious about making the decision not to include Medicaid in their insurance panels when starting practice. Will the next generation of clinicians be prepared or motivated to care for the poor and disabled?

Somehow as clinical teachers we have failed; somehow we have not been able to mentor and explain one of the traditions of our profession and specialty. The findings of Gazewood and colleagues are not limited to Missouri. They seem to permeate the spectrum of primary care.

Autonomy may make clinicians more satisfied, but the problem is much more sinister and perverse. It is no longer politically correct for those of us in primary care to shake our fingers at our specialist colleagues and accuse them of “cherry picking” or taking the “cream off the top,” since these phenomena are now also firmly entrenched in primary care.

I am not confident that autonomy in clinical decision making is going to change this. The circle has been broken.

Most physicians will nod their heads in agreement as they read “Physician Satisfaction with Medicaid Managed Care: The Missouri Experience” by Gazewood and colleagues (J Fam Pract 2000; 49:20-26). The results from that article concur with our feelings about caring for patients with Medicaid coverage. It is a frustration that is common among family physicians.

As with any study that coincides with our prejudice, physicians will be pleased to see that someone has done the research necessary to provide data. This data can then be quoted to those who manage managed Medicaid programs as proof that there are problems. The bullets on an executive summary of the results would look something like this:

• Medicaid continues to be a frustrating endeavor for many physicians in primary care.
• Physicians in Missouri are dissatisfied with Medicaid managed care in comparison with fee-for-service Medicaid and commercial managed care.

Gazewood and coworkers sense that autonomy in making clinical choices is the critical issue for determining whether a clinician will be satisfied with the Medicaid revolution that is sweeping the country. Their study gives lesser weight to the role of equitable compensation for the provision of health care services. They argue that it might be necessary for the designers of Medicaid managed care to incorporate physician autonomy into the formula for success.

Autonomy and compensation

I have difficulty separating autonomy and compensation. In some ways they are so intertwined that discussing them separately seems shortsighted. Autonomy in making clinical choices is limited by rapidly disappearing specialty clinicians, who choose not to participate in Medicaid because of low compensation rates for their services. In many primary care practices this has accelerated to a crisis issue. For example, in my community there are delays of several weeks to have children seen by neurologists, since there are only 2 in the state who will evaluate Medicaid patients.

As a family physician, I am taking increasingly greater risks in the care of my Medicaid patients, because I can rarely find local assistance in the specialty ranks. The delays prevalent in the specialty care provided 100 miles away by waiting list only has taught me much about compromise and marginal quality care.

I have such autonomy at this level of care that it frightens me.

This crisis is not simply a specialist/generalist issue; family practice as a discipline must also bear a sizable portion of the blame. We now have a number of family physicians in residency training who consistently stay away from any Medicaid contract, as they begin their practice. Is this because of the frustration that family practice residents endure while caring for this group of patients during their training? Is it because of an attitude taught by frustrated faculty?

Whether a residency program practice, with its legions of seemingly ungrateful Medicaid patients, or the specialist preceptors who will not provide care or consultation are to blame is unknown. But I am concerned that we may be creating a catastrophic trend. Many of our most talented residents are not the least bit anxious about making the decision not to include Medicaid in their insurance panels when starting practice. Will the next generation of clinicians be prepared or motivated to care for the poor and disabled?

Somehow as clinical teachers we have failed; somehow we have not been able to mentor and explain one of the traditions of our profession and specialty. The findings of Gazewood and colleagues are not limited to Missouri. They seem to permeate the spectrum of primary care.

Autonomy may make clinicians more satisfied, but the problem is much more sinister and perverse. It is no longer politically correct for those of us in primary care to shake our fingers at our specialist colleagues and accuse them of “cherry picking” or taking the “cream off the top,” since these phenomena are now also firmly entrenched in primary care.

I am not confident that autonomy in clinical decision making is going to change this. The circle has been broken.