Thoughts on Health Care from a Practicing Physician

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Poor medicine! So much of the healthcare mess has been blamed on our honorable profession, an art that dates back thousands of years to Hippocrates.  The art of medicine in America today, however, is almost an endangered species.

As a doctor in private practice since 1981, I had the chance to learn to be a physician before the existence of electronic billing and Medicare assignment, DRGs, MRIs, and the HMO.   More time was spent one-on-one with the patient, figuring out the diagnosis, educating and counseling.

Now our time is spent primarily in documentation, used both for getting approvals and payment for services.   Use of the electronic medical record has placed a new distance between the physician and patient.  Time with the patient is limited by a demand for efficiency and “production,” and the easy, least liable response to many problems is a quick referral for imaging or consultation.  If the test is negative there are more tests.  If something shows up, that’s what is often treated without much thought as to the relationship to the original problem. Analogous to teachers now “teaching to the test,” medical providers are “diagnosing to the code.”

The political discussion is about funding healthcare, i.e. insurance, not the practice of medicine itself.  Unfortunately, the terms are used interchangeably and are seen as more and more equivalent, actually driving up costs.  Why do we seem to be spending more and more and getting less and less? The reasons for the dramatic rise in costs relates not to just the rapid advances in technology but, to a great extent, to the thick layer of tangential businesses such as insurance, pharmaceuticals, and medical device companies.  From the physicians’ standpoint, the greatest increased cost of doing business relates most to the expense of running the business: pre-approvals and appeals, billing, documentation for that billing, and delays, discounts and denials by payers.   The management of medical money has become a large separate business having nothing to do with direct care of the patient; it’s medically necessary only to keep the place running.  Talk about waste!

In truth, I personally dropped all my private office contracts with all insurance companies, including Medicare and Blue Cross, several years ago, though I am still contracted with several under the separate entity of Children’s Rehabilitation Services.  It didn’t happen overnight.   The first group I quit was probably still in the 1980s when a local physician-controlled health maintenance organization had a rotating group of  member-doctors who reviewed all referrals, sometimes denying them and referring to themselves instead.

In the middle 1990s, I dropped out of another program because they were dishonest with me regarding the availability of a second specialist in my field to take overflow referrals, and threatened the group’s business office with withholding payments unless I made room in my schedule to see their patients sooner than those in other insurance groups.  At the time this local insurance group represented 60% of my patient population, I was booked six weeks in advance, working 50 hours weekly and being asked if I’d like to push it up to full-time.  After dropping them, for a while I was only booked for two weeks ahead and still had all the patients I needed.  A large national health insurance corporation has since swallowed up the HMO.

When starting another solo office in 1999, I signed up with many insurance plans, contracting as a participating physician and agreeing to take direct payment from the insurance company.  After the first year or two it was apparent that I was much busier than I could handle alone, but instead of expanding, I chose to shrink my practice, allowing more time with each patient and a much more relaxed life for myself.

Eight years ago I was taking only Blue Cross and Medicare, also working with personal injury, industrial and legal aspects of medicine.  I now practiced a specialty caring for back pain and other chronic injuries, problems not well served by our standard medical approaches (indicated by an epidemic of chronic pain problems).    A growing side of my practice included treatment of soft tissue injuries and pain with injections that are outside the mainstream of conventional medicine.   My patients were more and more complicated, it took 45-60 minutes with each patient, sometimes as long as two hours.   At the time I dropped Medicare, they were still paying me the rate for a 15 minute office visit for one of those hours

My documentation could not support the expected “evaluation & management standards” that were expected to gain higher payment.  My billing service warned me that time spent alone was not sufficient justification for a higher payment but I was expected to document a multitude of repetitive irrelevant details at every visit if I wish to up-code (to the rate they allowed for a 30 minute visit).

There was a fear of an audit triggered by too many injections, but there were no guidelines as to how many injections they recommended or allowed, and every patient was unique.  There was also a fear of the new privacy rules, just released at that time; every practice was attending expensive seminars put on by private agencies interpreting the new regulation and having them revamp entire office setups.

At the time I dropped Medicare eight years ago I was basically going broke.  My annual income was lower than it had been in 1983; Medicare held back payments for six months because my biller at the time did not understand that the requirement of one number on one page that had changed that year.   Some of the injections I performed in my practice were not approved by Medicare anyway, but in order to charge Medicare patients for them I was required to receive my denial from Medicare in each instance, delaying the billing for those treatments by several more weeks and months.  And then I received three five-cent checks in the mail within one week from “supplemental” policies.  The idea that the insurance company could afford the 43 cent stamp and paperwork to send me a nickel showed me where I stood within the system.

Dropping Blue Cross and Medicare, I found myself again booked only two weeks ahead but still working all day and enjoying the ability to follow people up more frequently without stressing over the numbers of patients trying to get in.   My practice is now much more manageable and I can still run it as only one person with one and a half employees.  My direct overhead went down by at least the 10%  that I was paying the billing service, we now do it all from the office.  We still work with pre-approvals and try to get patients help getting their physical therapy and imaging studies paid for.  My charges are small in comparison, and approximate those of a dentist or psychologist.  I feel free to offer a sliding scale and barter, and I have not sent anyone to collections in eight years.

Mine is only one very low tech medical practice, one that I hope is keeping the art of medicine alive in some way, as well as improving the treatment of some frustrating problems.

At the same time, I am an unequivocal supporter of a National Health Program.   For me, the new healthcare legislation unfortunately left out the public option.  I speak from a personal point of view, having privately provided health insurance for my family and staff for the past 10 years without the cushion of the large group poor employer policies.    Premiums are exorbitant and coverage is unpredictable, not every hospital is “in network”, we have a deductible of several thousand, and my husband’s collapsing arthritic knee has been denied by our policy since the beginning.   As an employer, the cost of my employee’s health insurance is about 5% of my total overhead.  Medicare and Medicaid look good to us. When I dropped insurance, Medicare was the last not the first, it was the most predictable and fair.

A central question:  Is it a right to have health care, or not?  There are certainly those of the opinion that without the ability to pay, you shouldn’t be able to receive.  Where’s the line?  Do we let people die?   On an individual basis, can one walk away from a person who is in obvious trouble?  Hospitals are a necessary and fundamental part of the community.  Where else do we go with broken bones, heart attacks and our aging loved ones when they become ill?

But just how much healthcare is a right?  What exactly constitutes medical necessity?  One definition is whatever is needed to “preserve life and limb” but obviously we expect much more out of our healthcare these days including attention to the aches and pains of aging, routine colds, flu, and allergies.  Public expectation of healthcare has soared, greatly fueled by advertising and warning labels, all encouraging patients to “speak to their healthcare professional” about various products.

What do we actually need?     At the very least hospice, hospital and trauma services should be publicly funded, similarly to fire stations and police departments. Then, support a basic system of clinics for both routine and urgent healthcare available to any citizen, similar to the VA and County health care programs, and you have the beginnings.  Create a second tier of care for access to the private medical system, structured like Medicare Part A & B now. The system is already in place.

As it is now, Medicare still excludes many items.   There needs to remain the freedom to choose a privately paid physician (similar to your psychologist or dentist) who could act as a medical counselor or broker, and the right to seek treatments that may not be funded by the public system (think cosmetic surgery and purely alternative medicine practices).  The medical professional must retain the right to practice within a public or private setting.  It works for education.

Medicare-for-all could be paid for by a fraction of the premiums that we are paying now. We would just send that money to the program instead.

I would recommend to you the many years of data accumulated by Physicians for a National Health Program (www.pnhp.org).    The coordination of so many different payers and criteria are a waste of medical time and expense, I would guess an average of 20% of the overhead of each office.  A single-payer would also eliminate the expense of profits, advertising, and executive pay.    Private insurance will continue its role in providing for uncovered expenses, long-term care (though in most countries with a single-payer system, long-term-care needs are also easily met with a system spending fewer dollars than we are spending now.)

Healthcare cost control means many more things.   Between 1969 and the present, medical advances have seen the introduction of MRIs, fiber-optic scopes, widespread usage of joint replacements, exponential increases in numbers of people having back surgery, and exploding pharmaceutical costs.   Our expectations are over the top. Tort reform is also a critical subject. It is still unclear just who is liable for failing to fulfill expectations.

The debate will continue, the interests of big business will continue to dominate for a long while; there is much money to be made from the nuts and bolts attached to the practice of medicine.  It’s time to put some honest numbers out there.   From the position of the frontline, the first order of business is to get back to basics, clarify our expectations, and simplify the system; it’s the only really fair way to pay for more with less.  Perhaps this writing will turn into a series to help shed some light from a new perspective.

Debra Walter, M.D.                                                                                                                      7/9/11

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We are pleased to present as our first guest blog, with our great appreciation, this informative discussion of healthcare issues by a practicing physician, Debra Walter, M.D.  We look forward to more of her valuable insights in future submissions!

ARC, JMH  – 7/9/11

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