I am a practicing primary care physician and manager of an outpatient multi-specialty physician group and an inpatient hospitalist company. In these capacities I get to see a broad perspective of the care that patients receive. The piece by Peter Salgo in the NY Times is too narrowly focused and misses the mark on one of the real problems in health care. It is not that physicians don't want to talk to patients, or are greedy, but rather that the health care system in the United States has taken control away from physicians, and given it to large corporations such as hospitals, health care systems, health plans, drug companies, and biomedical equipment manufacturers. The compensation system and the politics of health care in the US today pay well for high-tech procedures, drugs and hospital care. Similarly the lobbying effort of these companies, both at the that the state level and the national level, has created an atmosphere in which, hospitals and their health systems are essentially monopolies that favor and foster the above profitable components of health care delivery. In many states a certificate of need requirement for high tech procedures such as MRIs, PET scans and freestanding surgical centers prohibit competition. The result is that hospitals and their care delivery systems can charge more for, and have looser criteria for performing and inter-referring for, expensive tests and procedures. This scenario makes for a very high cost health-care system. Physicians, working in these facilities, are more geared to head toward technology ,both from training and mindset, then they are toward communication skills and personalized care for patients. "Knee jerk" care and testing for any abnormality has become the norm in the hospital and emergency room setting.
Similarly, outpatient care and preventative care have been de-emphasized. Medicare and health plan reimbursements for what are called E & M, evaluation and management, services which basically means the patient communication part of healthcare, are at a relative all-time low. So much so that very few graduating medical school physicians go into primary care or fields that emphasize patient communications skills. The result is that physicians talk less to patients because there are too few doctors trained properly to do so, and it simply doesn't pay enough so that an outpatient office can be managed in a reasonable manner. Primary care physicians' overhead expenses are typically 60 to 70% of their gross income. These diagnostic communicative physician specialists have had a continual relative decline in their incomes. Few graduating doctors are going into primary care. That is one of the key reasons why emergency room visits are dramatically up, and subsequently why patients, whom are unknown to the ED doctors, receive expensive technological care and frequent unnecessary admissions to the hospital.
The American health care system by virtue of its emphasis on expensive technology and inpatient care has created the most costly system possible to take care of extremely ill, frequently near terminal patients, who, all to often are likely to die within six months despite this dramatic care. Meanwhile we have moved away from personal preventative care that patients need and want most. Until the system deals with these perverse incentives the current pattern will continue.
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Comments: 31
Medicine has also due to knowledge needed become highly specailized. The problem is knowing who to ask for and when.
It is scary to know one's healthcare is ultimately decided by insurance 'guide lines' and some administrator at an insurance company ... not the physican treating me.
When doctors are not able to talk with their patients, as you indicate in the kind of training that is going on now, the patients and their families feel more isolated.
An excellent and timely article. You clearly pointed out the culprits in today's general practice world.
I recently graduated with a degree in medical coding. During my internship, I was shocked when I saw the contracted amounts by Blue Cross Blue Shield, United Healthcare and other commercial carriers - not to mention Medicare. In some cases an office visit was funded for less than $20. Like everyone else, I had heard that the amount of reimbursement was dwindling, but until I saw the numbers, I simply didn't believe it.
What was even more disturbing to discover, was the red tape and delaying tactics used in payment by these carriers. Most invoices are transmitted electronically these days. One would think this would streamline the process - however, the opposite has proven to be true. Denial of claim due to "missing" data happens all too frequently. (Part of the claim made it through, but something like the provider's ID# did not - go figure?) Then of course, there are denials requesting a copy of the insured's card (even though pre-authorization was obtained) or the all encompassing request for "notes."
Why delay? That's an extra 60 days or so for the insurance companies to hold on to their money. The fines and penalties for doing so are sufficiently below the amount of profit to be made by these practices - so they get dinged, and they pay - but nothing changes.
Is it any wonder that general practioners are an endangered species?
I do check in with my primary care physician once every year or so, just to make sure he remembers he is my doctor. On those occasions he tends to talk at length with me about any concerns I may have. That is one of the beauties of living in a small town. The doctors are not usually rushed.
A big problem I don't see mentioned in these discussions on health care is the near-obscene proliferation of drug pushers on TV. They try to persuade people, especially elderly ones, that they need all manner of medications for ordinary situations like indigestion, which can be alleviated by eating wisely; and insomnia, which yields to non-pharmaceutical measures in most cases. Since they are required to mention the awful side effects of the dope they are pushing, the advertisers rush through them in an almost comical parade of horrors, including symptoms that those particular drugs are supposed to remedy (nausea, for example; diarrhea, for another). Why can't we just eat moderately, exercise faithfully, meditate instead of medicate, etc., etc.? Because it doesn't line anybody else's pockets.
In the US, we rely heavily on the health insurance system to pay for our care. In the past, huge swaths of Americans were covered by traditional indemnity care and most of these insurance companies were non-profit and member run (i.e. there were no shareholders -- policy holders were the owners, like Northwestern Mutual and USAA are today).
However, like everything else I suppose, insurance companies, with their large cash and asset reserves became attractive as engines to drive profits instead of care.
In my mind, profit motives and health care motives are at cross purposes. They cannot coexist comfortably without injuring one or the other.
While I understand why physicians and others in the health care field reject the idea of "socialized medicine" (and for good reason), private sector solutions do not help (as evidenced by the tremendous number of Americans who are uninsured) and government-run solutions seem bureaucratic and overbuilt.
Tough questions with no easy answers.
Thanks for sharing your perspective!
What's happening to physicians parallels what happened to teachers about 2 generations ago. Believe it or not, the education system used to be run by teachers, and teaching was a respected profession. Look at it now. The teachers are the hacks at the bottom of the pile.
This issue will become more and more pressing as our population ages and more patients are dealing with mild memory loss or even dementia. In the current system, the patient must the be expert communicator and case manager in order to get the right care. That's hard to do when one is laboring under cognitive impairment. (Now where are my car keys?)
for those of us without insurance, it is even worse. we pay a LOT for a tiny bit of time. not fair, either.
greed is the root of all evil.
everything the doctor just described is a direct result of maximizing profits, minimizing expenses - and avoiding litigation - but not just in healthcare - ALL areas of our lives have been put on a respirator and a drip-line.
schools have been systematically underfunded and kids have been systematically under-educated. we're having a huge debate in california about a high school exit exam requirement for getting a diploma. also a big stink about executive compensation at state universities, where tuition has risen at phenomenal rates in the last several years.
under-educated, broke - no choice but to enlist or steal.
the two biggest issues facing the healthcare industry, and the doctor can back me up on this - are medicaid/medicare reimbursement, and the ever-growing uninsured population - which they call Bad Debt.
i'm sorry - i'm about to go off on a huge rant here. good post, dr rubin - but i hope everyone begins to see that the illness you describe is caused by greedy politicians who have been playing our wallets for faaar tooo long, and have all the angles down, all the right people in all the right places - and we're just shoveling the money out.
don't know what the solution is. the problem extends to people in government who are not elected, but work around politicians. cabinet members, etc.
NO MORE BIG BUSINESS IN GOVERNMENT.
no more OIL men responsible for formulating energy plans.
no more LAWYERS responsible for creating healthcare policies.
the only way to do this is by fostering a healthy sense of shame for people who are caught being corrupt. force them to wear underwear on their heads at all times, or something.
bring back public stockades in d.c., perhaps.
help me here, folks...
I like that you fault the system, but I think that you ought to look at a different way of reforming it!
I sincerely wish you the best of health.
the words "healthcare" and "for-profit" should never coexist.
why are churches considered non-profit and tax-exempt?
jesus.
You have described in essence a frightening devolution of medical care from thorough patient--doctor communication with carefully considered treatment, to high cost and often unnecessary tests and treatment modalities in an effort to make the highest possible profit. It is a shameful state of affairs when physicians avoid primary care for the very reasons you stated. Furthermore, from my own experience, HMOs and insurance companies, with their "gatekeeper" decision makers, are essentially practicing medicine without a license. When my cardiologist, whose care I had been under for a year ordered a 24 hour holter, the request was turned down because, "...patient has no history of heart disease." Hello...what exactly was documented arrhythmia and syncope? In a fit of pique I told my doctor, "So, what it all boils down to is my HMO is practicing medicine without a license?" He nodded angrily and said, "You got that right. Let me call them and give them a few essential facts." He subsequently ordered more extensive and comprehensive tests instead of the holter, and those got okayed.
2. Reliance on drugs rather than natural processes is appalling.
3. According to information I can glean frompublic records and Philadelphia magazine, a newly minted doctor can earn 5X what a teacher with 20 years experience and a doctorate can earn. That's obscene, and clearly points to the basic greed motive of many doctors.
4. The exact same drug costs 50X what it costs in other countries. last Dec. i was in a backwater area of Ukraine and came down with pneumonia. Warned by local expats not to go to the local hospital, I phoned my Dr in Philadelphia who ascertained that I could buy anything I wanted OTC in Ukraine as long as I knew the name, and he recommended one. I saw him when I returned; he looked over the pills I had left and the package and was assured I had what he ordered. I paid under a dollar for the full course, less than the copay would have been here back when my husband was alive and I still had health insurance from his jobl Now I have none and do without medicines and Dr visits as much as possible. The pension simply doesn't pay for both food and medicine. If the drug companies can sell their pills so cheaply in Ukraine, why can't they charge a whole lot less here?
5. The AMA , drug pushers and other power groups simply have got to stop fighting national health care, I lived in Spain as a young wooman, was a teacher there for several years. I experienced European style national health care and can't say enough good about it. *Everybody* gets the same quality of care, no favorotism based on income or anythiing else. Prolonged illnesses don't cause loss of jog; the law sees to it that your job is kept for you and you get your full salary throughout. If somebody in your household goes to your neighborhood health center with your card and fills out a form, the doctor is in your own house to see you that afternoon. You don't have to drag yourself out of bed with a fever and drag yourself there! Here, having to drag yourself to the Dr is likely to make you sicker!
6. The MD types do not respect or value to enormous good done by acupuncturists, nutritional therapists, massage therapists, chiropractors and similar natural-drug-and-knife-free health care providers. They keep insurance companies from including this natural care in coverage and they try to talk their patients out of using it.
My Dr shanghaied me into a flu shot several years ago. It promptly made me sicker than I had been in dogs years. When I was well enough to crawl out of the house supported by my husband and into a taxi, I went for acupuncture--and was completely well the next day.
7. Acupuncturists, chiroprcators and massage therapists actually talk with you as much s you need. And when you have no insurance, 30 minutes with one of them costs considerably less than 7 minutes with the MD. It's a no-brainer.
I think one area of recent study that should be considered in reform is Evolutionary Medicine. In fact, everybody should read Nesse's "Why We Get Sick".
I had an interesting lesson in the economics of healthcare when I had my gastric bypass surgery. I am extremely lucky in that I have a great insurance plan -- my surgery was approved almost overnight. But I know many people who have gone through numerous rejections in the process. This didn't make even economic sense to me. For instance, in my case, the surgery resolved my diabetes so I have gone from taking four shots a day to none, to a normal blood sugar level. This means that the insurance company doesn't have to pay the very considerable (and ever-rising) costs of my diabetes care, so one would think the insurance companies would see the surgery as an economic boon. But as someone pointed out to me, becaue of changing American work patterns, the insurance companies don't expect you to stay at the same job for very long, so they don't expect to be insuring you for more than a couple of years, so they don't get the "long term" financial benefits of our improved health. So they don't care. So the long and the short of it is, they really don't care whether you get sicker, just so long as you're not doing it on their watch.
martinchill is absolutely correct: it's all about corporate greed and government. I wish I could remember her name, but there was an author on the Daily Show a few weeks back who had outlined the effect of corporate lobbyists and their money on Washington, D.C. and her conclusion was that at this point, our government is totally owned by big business. We need to wake up to this fact, and do something about it.
One of her recommendations was to have government funded elections. If we paid for elections and campaigning and allowed NO individual fundraising for campaigns, it would undercut the need for Congresspeople to gather more and more money to run a decent campaign. As she pointed out, it might look as though it was more expensive, but in the long run, the American people would be saving untold billions of dollars by not having lobbyists run the government. Because at this point, the bottom line is, if you don't have money backing you up, you're not going to get elected.
To my mind, this is the great threat to democracy, far greater than any foreign threat we can imagine.
Our Health Care system is a horrible mess, and not because of our physicians.