Real medicine

Mar 09 2011 Published by under Medicine

A number of years ago I wrote a post about why your doctor always runs late.  I have no idea where the link is, but the general idea is this: you only have so many hours in a day, and lots and lots of patients want to be seen.  There are only so many primary care docs, and so many spaces on a schedule.  So you schedule people as tight as you think you can get away with, and toss in some add-ons who call to be seen the same day, and generally hope that the couple of people who no-show will leave some gaps for catching up.  My own schedule has a 45 minute lunch built in, but that never really happens, and all it takes is one person with pneumonia or chest pain or depression to throw the schedule out of whack.  This is cold comfort to those who sit around waiting forever, the only consolation being once I'm in the room with you, I'm yours for as long as is needed.

My post on this phenomenon garnered the expected griping about the patient's time being just as important as the doctor's, etc., an idea that I appreciate but that is short-sighted.  Doctors are, for better or worse, a limited resource, and patients are stuck competing for that resource.  When someone demands to be seen immediately, it is another patient whose time they are taking.   Of course, with our inefficient, non-science-based health care system, I can probably get you an MRI of your entire body done in a few hours, but I still can't get into your room on time.

All that aside, real medicine---the good kind---takes time.  It may only take me a few minutes to diagnose a cold, but it may take me several more to explain why antibiotics aren't needed.  In a more paternalistic system, the patient would be told, "You have a cold, go home and have soup" and shuttle out the door.  In a harried, "bad medicine" office, you would probably be given some Miraculocillin for $10 a pill and sent home.  But to practice good medicine, you have to sit and explain what your are recommending and why, and then sell it, because even though patients are competing for your time, you still want to keep them coming back, both for business reasons, and  for medical humanitarian reasons.  Practicing good, humanistic medicine is a lot harder than practicing bad medicine.

All sorts of things can toss a monkey wrench into the daily schedule, not just someone who is severely ill and needs extra attention.  A patient may come in after a hospitalization, and after getting the story from the patient, I'll have to log in or call the hospital to dig up records.  I don't expect someone to give me an accurate accounting of their prolonged hospitalization, so I'm left to do the detective work (which is usually interesting).  I may have to fill out new insurance physical forms since patients often change insurance companies frequently.  Each of these forms has slightly different requirements, and if I screw it up, the patient will pay higher premiums.

I may find a patient who seems to have a simple infection didn't do well on an antibiotic, and have to look up local resistance rates to see what new data from the community can help me make a better choice.  I may need to look up the latest recommendations for screening for one disease or another, or I may have to figure out if a patient's insurance covers preventative care or not.  I may need to set up a consultation with an expert, calling them to explain the situation and asking them to make room in their own over-crowded schedule.

The day-to-day practice of medicine, when done well, is complex because it deals with human beings.    But it gets even more complicated.

Under our current system, I get paid for what I do, that is, I get paid based on the complexity of an office visit, and for any procedures that I may provide.  Most doctors are not salaried, and the rates charged are essentially non-negotiable, based largely on the way big insurers such as Medicare and Blue Cross do things.  I recently moved my practice 2.5 miles down the street.  I can nearly see my old office from the window of my current office.  Despite this, I have to re-credential (which is apparently a word, according to insurance companies) with Medicare, Blue Cross, and all of the other insurance companies that we work with.  Even if they have current copies of my license, etc, they need them all again, and will take months to get me into their system at my new practice.  I moved in December, and I was finally re-approved for a bunch of the smaller insurance companies. Medicare is still working on me. This means that my practice has not been paid for my work for the last three months.

Some would argue that this shows how dangerous a single-payer system would be: imagine if Medicare were in charge of everything!  The converse is that dealing with a single entity would be a helluva lot easier than a dozen.  The paperwork is astounding and expensive, and cuts into patient care.  So while insurance companies push at doctors to adopt the latest model for reimbursement (with phrases such as "meaningful use", "patient-centered medical home", and "accountable care organization") doctors are busy trying to see patients, and trying to not lose money by doing so.

I'm cynical enough to know that there are problems with a single-payer model, but from the standpoint of a patient and of a busy practitioner, the paperwork couldn't get any worse.  And from a social justice perspective, it's a no-brainer.

10 responses so far

  • Well, I think we need to decide what kind of society we want to be. As it stands now, there myriad barriers to access to healthcare, not the least of which is your time being wasted by unnecessary bureaucracy. As it stands now, the entire system seems a bit like social Darwinism to me, and I am one of the "lucky" ones with private insurance.

  • Having grown up in one of those evil socialist European countries with universal healthcare and subsequently moved to the US, I just can't believe the paperwork - and that's from the patient's end!

    I also can't understand how you are supposed to budget for your healthcare needs when the practice can't tell you until they've filed how much you will end up paying. And you can potentially end up with a several thousand dollar bill if it turns out you or they were wrong about what is and isn't covered.

    And then there are the multiple bills from different departments... random extra bills from the Association of Anesthetists, or whatever, that turn up weeks later... Just who the hell is running this show?

    • Not to threadjack, but one of my co-writers at Does This Make Sense wrote about having her appendix rupture and the costs associated with that even as someone who has insurance.

      • D. C. Sessions says:

        If you want to get seriously offended, have a look at the lab bills. I'm insured, and part of that is that my statements show what the lab would charge if I weren't. Sam off the street is looking at ten times what I get charged before the insurance covers it.

        That, people, is just plain wrong.

  • Dianne says:

    I've taken to saying that the only thing worse than having no health insurance in the US is having health insurance. I've got a lively practice of glioblastomas. The first line treatment for glio and a number of other brain tumors is temodar. Temodar is a chemotherapy pill and is extremely expensive. Insurance companies look for any excuse to reject efforts to get this medication. I've had forms returned because the patient didn't print his or her full name, the time that the patient signed was different from the time I signed (by 5 minutes) and because an older, less effective and higher side effect drug regimen had not been previously tried. It's total madness. And yes, I've been HOURS behind schedule because the insurance company kept me on the phone for that long, attempting to get a preauthorization.

    In contrast, I used to work at the VA. I won't say the rules at the VA were always logical or the administrators always helpful. That would be untrue. But there were two factors that made them easier to deal with than private insurers:
    1. There was only one set of rules to learn. Some of the rules were illogical, but once you knew them you knew them and there weren't 10,000 slightly mismatched illogical rules to learn.
    2. The administrators approving requests couldn't care less if your request was approved or not. This is a great advantage over administrators in the private sector who are paid by the number of claims rejected.

    So, ultimately, I'd be happy with single payor. I agree that it's only realistic to expect there to be problems with a single payor system, but they're likely to be less severe than the problems in the current system.

  • William Wallace says:

    I don't know about now, but past experience in China shows that you cannot stop a free market. You can only change the currency. There, if you wanted the best surgeon, and you wanted a good outcome, gifts and parties were the cost.

    In the U.S., I can't see how the government can stop a doctor from making a lot of money, and I don't see the type of corruption found previously in China (perhaps still). But if you toss progressive taxes on him, he'll take longer vacations. If you regulate pay for primary care, and patient hours per year, doctors will gravitate toward those specialties that still allow high incomes, or other professions. We will still have doctors, perhaps from India, Pakistan, Cuba, or elsewhere, as well as Peace Corp types who don't care so much about getting paid as doing what they love.

    The same thing has *already* happened in public education. Teacher pay is controlled by an unholy alliance of governments and unions. The pay is low. The work product is political. Teachers hands are tied. Smart women have little financial incentive if they can earn 2x or 4x doing something else. You do find some smart women in public education still (Peace Corp types, or the wives of doctors or financially secure breadwinners), but public schools have to compete with other sectors financially, and it has taken a toll on the quality of teachers in the teaching pool.

    Now, if there were maximum limits on what anybody could earn, then we'd all have 8 week vacations, and society would be perhaps considered "just" in your mind. We may end up there, if the lefties somehow survive the next election.

    • Dianne says:

      I'm not sure why you're looking at China as an example of how a universal health care system would work. True, it has pretensions of having universal health coverage, but it's by no means the only country with such or the one most comparable to the US. Why not look at Germany, which has the oldest universal health care system, dating back to the 19th century? Doctors there are generally quite contented and well paid. There are lots of primary care physicians. In fact, the crisis I heard of most recently is that it is excessively difficult for young graduates to start a practice because older physicians just keep practicing and so many people want to go into medicine that most places are oversupplied with doctors, including for primary care. Can the US say the same?

  • William Wallace says:

    Germany to a greater extent than China is ethnically and culturally homogeneous. China and the former Soviet Union were not (though to white people it might seem otherwise).

    It is easier to have a one size fits all solution in countries, like Germany, where the people share a common culture and ethnic background, and, if history serves as a guide, are already predisposed to believe they are the state's chattel.

    Besides, even in Germany, it is not one size fits all. Private health insurance exists, and people are free to opt out of the public system. Even then, the private system has onerous requirements that limit freedom (e.g., people are compelled to save up for anticipated higher medical costs when they get older). Not that saving is a bad idea, but a government forcing people to save is a bad idea. It is the classic problem of macro versus micro. What is good for a population may not be good for an individual. When a government or institution compels a population to behave as though every individual is the average of the population, injustices ensue. One might argue that the sum of the injustices are smaller when the government does this, but that is an end justifying the means argument.

    I think they should ban health insurance, except for major unexpected event health insurance. Pre-paid medical care (e.g., for checkups) is not insurance anyway, and results in increased overhead/paperwork/employees and drives up the cost of getting a physical.

  • Matthew F. says:

    "I don’t expect someone to give me an accurate accounting of their prolonged hospitalization, so I’m left to do the detective work (which is usually interesting)."

    Reminds me of tech support - what the customer says is the problem is usually a clue, but the problem is rarely what it immediately suggests to them.

  • Eli Rabett says:

    Well, a large part of this discussion in the US is that most simply have never functioned in a working health care system. A good place to start such a discussion is an article from 2007
    Medicine may be hard, but health insurance is simple. The rest of the world's industrialized nations have already figured it out, and done so without leaving 45 million of their countrymen uninsured and 16 million or so underinsured, and without letting costs spiral into the stratosphere and severely threaten their national economies.

    Even better, these successes are not secret, and the mechanisms not unknown. Ask health researchers what should be done, and they will sigh and suggest something akin to what France or Germany does. Ask them what they think can be done, and their desperation to evade the opposition of the insurance industry and the pharmaceutical industry and conservatives and manufacturers and all the rest will leave them stammering out buzzwords and workarounds, regional purchasing alliances and health savings accounts. The subject's famed complexity is a function of the forces protecting the status quo, not the issue itself. . . . .

    It's a common lament among health-policy wonks that the world's best health-care system resides in a country Americans are particularly loath to learn from. Yet France's system is hard to beat. Where Canada's system has a high floor and a low ceiling, France's has a high floor and no ceiling. The government provides basic insurance for all citizens, albeit with relatively robust co-pays, and then encourages the population to also purchase supplementary insurance -- which 86 percent do, most of them through employers, with the poor being subsidized by the state. This allows for as high a level of care as an individual is willing to pay for, and may help explain why waiting lines are nearly unknown in France.

    In order to deal with moral hazard and foster preventative health care where it counts
    In order to prevent cost sharing from penalizing people with serious medical problems -- the way Health Savings Accounts threaten to do -- the [French] government limits every individual's out-of-pocket expenses. In addition, the government has identified thirty chronic conditions, such as diabetes and hypertension, for which there is usually no cost sharing, in order to make sure people don't skimp on preventive care that might head off future complications.

    Folks in the US need to get serious