Health Care Issues in America
The morale of physicians and other health care professionals has been sinking significantly over the past few years for a number of reasons related to the medical industry…
• Declining reimbursement – Government-sponsored health care insurances plans are very much in control of primary care physicians’ reimbursement, so much so that most of these doctors can no longer afford to maintain their own independent practices. They have had to “sell out” to larger organizations, which further control how doctors have to take care of their patients in order to “improve the bottom line”. Thus, you now see doctors trying to cram in 40 patients a day into their office schedules, because high volume is the only thing that works financially. Is it any wonder that patients feel rushed in and out of offices? Do you think that’s how the average internist wants to practice?
• Increasing overhead – This goes hand-in-hand with declining reimbursement to give a double-whammy to physicians trying to manage a small practice. In order to see a high enough volume of patients to make ends meet, you have to hire more nurses and more secretaries and receptionists. You need an extra person just to manage the phone calls and another one just to fill out forms and take care of referrals and pre-authorizations for medications or tests that health care insurance companies won’t pay for unless you go through a lot of hoops.
• Increasing paperwork – There is a HUGE amount of paperwork (real or digital) that goes through a small medical practice in one day with all the different and sometimes complex insurance forms that get declined if one line is left blank, the referral forms and pre-authorizations as mentioned above., test results coming in, letters to and from other health care professionals, home health agencies, etc., etc., etc. Doctors need extra staff to handle all this paperwork, and a good portion of it has to be personally reviewed, filled out and signed by the physician. So this adds another 1-2 hours of work to the day for which there is no reimbursement.
• Increasing documentation requirements – Doctors now have to spend large amounts of capital investing in computers and electronic medical record software. There is no way that it costs as much as $25,000 per doctor to produce and market these products, but that is what doctors have to pay to get information technology into their offices, not to mention the time lost in the first six months of learning the system and the fact that some of these EMR programs actually decrease patient safety. Nevertheless, this is gradually becoming a mandate by insurance companies and by Washington, but there is no help on the horizon from anyone to assist physicians in doing this. In the meantime, our income continues to be severely controlled and regulated, and never keeps pace with inflation or the cost of running an office.
• Having to work longer hours to make the same or less income – This is basically a result of the above problems. After seeing patients for 7-8 hours a day in the office, the average physician will typically have 2-3 more hours of paperwork and phone messages to get caught up on, and then go back to the hospital to see a few patients before visiting the nursing home to see a few more and then maybe getting home for a cold supper and then being interrupted by 4-5 phone calls throughout the night before starting all over again the next day.
• Less autonomy – Most physicians no longer have control of their own offices any more. They have had to turn their practices over to larger health care management companies to share expenses and to keep the overhead down. As a result they frequently cannot hire and fire their own employees. Their employees frequently get moved from one office to another within the system. Poor reimbursement and poor benefits offered to employees in primary care offices require that qualifications for hiring be lowered. Most of these offices can't afford to pay an RN's salary. Doctors themselves frequently get moved around within the company whether they want to be or not. They basically have to practice the way the management company wants them to practice. This is not necessarily good for the patient. The goals of patient care and the financial well-being of a company do not always have the same direction. You can pretty much guess who wins and who loses in that struggle.
• Patients expect their doctors to be perfect – We can thank the television and news media at least partly for this. Doctors pretty much have to be perfect all the time or there is a huge outcry. There will not be much news about the 20 lives the doctor saved this month, but if a mistake is made in a prescription that causes an serious adverse effect, this is big. Of course patients don’t know or care how much good you’ve done in your life. If you’ve made a mistake in their case, it’s 100% bad; and you are only as good as your last performance, even if you’ve been taking care of the person for 20 years. Therefore, there is tremendous pressure to beperfect. Being human, however, you can only be but so perfect, and I think most patients understand that, but an occasional one may not. You just have to be as careful as you can be, get consulting help when you need it and develop a good relationship with your patients to minimize your risk.
• Constant worry about medico-legal issues – As a good physician, you always want what’s best for your patients. You know it’s not necessary, but if you don’t order the $3000 MRI scan in every patient with a headache, you may get in trouble legally, even if you did the right thing by not ordering it. If you miss the diagnosis of a brain tumor and someone else finds it, your name is mud in the eyes of the patient, and if harm comes to the patient because of it, there may be a lawsuit. We all know this, so that’s why we throw away our training guidelines and go ahead with the test. This type of thing happens day in and day out of a busy doctor’s practice – all over the country. Think of the billions of dollars that would be saved if doctors didn’t have to practice “defensive medicine”.
You may be thinking, “What does this have to do with the art of patient care?”
The answer is that unhappy physicians have less incentive to be the kind of health care professionals they want to be - what they spent hundreds of thousands of dollars to become educated for. They have a more difficult time dealing with the stresses of everyday practice. They get “burned out” more easily than in the past. A tired, stressed, “burned out” doctor is less able to keep up a good bedside manner and an air of professionalism. As a result our reputations overall as caring, compassionate physicians begin to deteriorate. We often become cynical and hardened by the struggle. Many doctors are feeling this, but there is not much they can do about it.
Patients are feeling it too in a number of ways. Access to care is becoming much more difficult in recent times. Poor reimbursement from certain types of insurance companies is forcing doctors and/or health management companies to limit the number of patients they see in their offices with those kinds of insurance. The reason for this is that the reimbursement for seeing a patient with one of these insurances is less than the overhead cost for the visit. This is causing great difficulty regarding access to care, especially for our seniors. Organizations like the AMA (American Medical Association) and the ACP(American College of Physicians) are trying to help, but progress remains slow.
Patients are noticing this. Those who are over 65 are having to call all over town to find an office that will still take their insurance. One patient of mine said she could see why this was happening. She lives about 2 miles from my office and she told me that it cost more for the taxi ride to see me in the office than the amount of reimbursement we received for the visit.
Medical school enrollments are still high (partly because there are not enough medical schools) but the number of primary care physicians coming out of residencies is extremely low and getting lower. Most students are going into subspecialties rather than primary care. There is already a serious crisis in the health care industry with regard to shortages of primary care physicians, which will only get worse over the next decade. This will only lead to more problems with regard to access to care.
There has been a great pressure by Congress, employers and health care insurance companies over the past 30 years to try to reduce health care spending which truly is out of control, but they are trying to do it by squeezing dollars out of physicians, who are not the cause of the problem for the most part. They are an easy target however, because they would never “go on strike” or stop taking care of patients as a whole for lack of reimbursement. If this continues, primary care will be squeezed right out of the picture and we will just have nurse practitioners managing complex medical problems or even specialists taking care of colds, flu and routine medical follow-ups which they really don’t want to do; although some are doing this now because the need is so great.
My own opinion is that there either needs to be a deregulation of government-sponsored insurance plans or a greater reimbursement for physicians who agree to see patients in those plans. There needs to be a restructuring of who gets paid for what. Health insurance and health care management executives are getting millions of health care dollars while the ones with the greater number of years of education, who are doing the actual work of saving lives, are getting the shaft. Better tort reform is absolutely imperative if we are ever going to get a handle on health care costs. I don’t hear anyone in Washington talking about that at all.
And so the world is not perfect. It never will be. Hopefully, we can find ways to make it better.
Despite all of this, we are still professionals who need to rise above the fray and continue to practice our calling to the best of our abilities. This is, unfortunately what makes us “easy targets”, but it is the right thing to do. Our patients and humanity, overall, need us to do the right thing. I am hoping the governors of our society will notice.
This page was last updated on August 7, 2010.