Stop nickel and diming doctors

By | August 12, 2019

So, who doesn’t want a better health care system?

We are barraged with stories in the medical literature and in the public press about the terrible state of our health care system, what poor outcomes we have, the inefficiencies in care, complaints about the electronic medical record, inflated costs, lives ruined by medical bankruptcy, and massive social inequities in terms of access and quality of care.

Throughout our days taking care of patients, in all the different settings we doctors practice in, from solo practices in the community to large academic medical centers, from inpatient critical care units to outpatient family health centers, we see this playing out day today.

We hear our patients complain, and we often feel their pain.

They can’t get access to the care they need, interminable waits, medicines they can’t afford, battles with insurance companies, frustrations with the system from every direction, and more.

And the providers are just as frustrated. Dealing with prior authorizations, clunky electronic medical records, endless bureaucracy, and regulations, we find our days filled more and more with so many things that we want to do less and less.

We went into medicine, this calling, to take care of people, to help our patients move through the health care system and hopefully come out a little bit better off.

But everyone seems to be pretty exhausted, burnout is endemic, and such a large part of everybody’s day is spent doing these things, besides what we’ve all been so exhaustively trained for.

So if everybody wants a better health care system, why can’t we get one?

As far as I can tell, the constituency of those desiring a better health care system in the U.S. is, or should be, pretty much everyone.

It’s true, we can argue about whether a single-payer model is the best, Medicare for All, concierge medicine, socialized medicine, more government intervention or less, a hybrid system with private and public insurers working together, or just toss the whole system out and start from scratch.

Looking at the bottles of wine and whiskey on the shelf behind me in my office, I wonder whether we should just go back to the barter system (I prefer baked goods over liquor).

Striking physicians, or striking patients, does not seem like an answer, and standing on our soapboxes saying we’re mad as hell and we’re not going to take it anymore doesn’t seem to be moving the dial any further toward an equitable, efficient, highly functional, and foolproof health care system.

We let this happen to us, and by “we” I mean everybody. The system has become bloated, providers are stressed and overworked and overextended, working at home at night and on weekends, and not necessarily on things that actually help our patients.

We let the health care system change, evolve, and erode, such that we get seven minutes with a patient, and our patients must often leave the office feeling unsatisfied, and we watch them go feeling like we haven’t done our best.

When politicians have tried to revamp the system, they’ve made some inroads, but for some reason everybody starts fighting when we try and come up with the solutions that are needed to really bring about change.

How can a screening colonoscopy cost a patient $ 17,000? How can a lab test cost $ 80 in one facility, and $ 2,500 at another? A week in the hospital is more than most people make in several years.

Part of the problem is that defensive medicine has made us all chase our tails, over-testing, over-ordering, practicing in fear.

Has our litigious society forced everyone down an inflationary health care path from which there is no return?

Most doctors can’t plead poverty, but in the present economic circumstances we can’t blame people for choosing a more lucrative specialty or shying away from taking insurance, when at this point it almost costs more to see a patient than we get reimbursed for the care we provide.

Perhaps some small part of this may have to be that those physicians making the most money make a little less, while the primary care doctors get a little bit of a boost, along with a lot of other changes that need to happen.

The health care landscape today is so much a business that it feels like we are nickel-and-dimed to death, to the detriment of ourselves and our patients.

Shoving more patients onto your schedule may help make a budget line work out at the end of the year, if that is what we’re after, but that is not why we see those extra patients.

Every one of those interactions with our patients should be precious, taking place in a sanctified space in which everyone gets to voice their concerns and have their needs addressed.

We need tort reform, standardized fair pricing, leveling of the salary landscape, and a system that does a better job of oversight to prevent rampant fraud.

And somehow, we need buy-in from the insurance companies, the pharmaceutical industry, and the health care systems that have grown up into something as massive and unwieldy and unsustainable as the military-industrial complex of the 1950s became.

There are players and industries involved with health care who are making billions.

We can’t blame them, the opportunities are there, we let them go there unchecked, and as private businesses in a capitalist society, their interests are those of their shareholders, to make a profit.

Someone once described for me the difference between $ 1 million and $ 1 billion.

If I gave you $ 1,000 starting today, you’d have accumulated $ 1 million before three years are up, on March 9, 2022.

To reach $ 1 billion, if I had started giving you $ 1,000 a day starting way back in the year zero, we would still have over 700 years to go from today before you reach that billion-dollar mark.

And don’t get me started on the trillions of dollars that our health care system currently eats up. (OK, $ 3.5 trillion dollars and growing, 18% of GDP, over $ 10,000 per person — but I told you not to get me started.)

Unfortunately, as much as we think and work and innovate around the edges, it seems likely that we are going to need some sort of a revolution in health care to really bring about meaningful change.

Trying to squeeze in a few more patients, or limiting formulary medicines, or putting up more barriers to make it nearly impossible for patients to get the health care they need, just isn’t going to lead to a healthier population and a more satisfied group of doctors trying to take care of them.

Sure, a lot of people may be unhappy, but if we create a world where everyone in that constituency that includes us all is getting all the health care they need, with all the best outcomes, with safety, quality, and equity ensured, then we will know we’ve reached the patient-centered place we need to be.

These are the costs we need to bear, the price we all have to pay.

Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com


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