Tuesday, June 26, 2012

Intermission time...

These last few posts were, to shamefully reveal my Southern roots (as my wife constantly reminds me of), a "doozy!"  I'd like to take a quick moment to speak candidly about my choice to stop my practice, based on questions I hear a lot from my patients over the past few months.

Decisions, decisions....I could have gone on to join a group practice and seeing my patients as I still have many years left in my profession, but as you can see, I left that kind of system to do my "dream" practice.  I have no intention on going back as it would antithetical to my core beliefs as a physician.

I could have changed my practice to a cash-only or concierge (or boutique) practice.  I seriously considered this option.  However, I've prided myself in taking care of my patients and families of ALL socioeconomic groups, not based on their ability to pay or whether they have insurance.  Nearly 40% of my practice is a mix of Medicare, Medicaid, and uninsured patients.  With the economic disaster over the past 5 years, that number has increased.  Changing my practice would also be antithetical to my core beliefs as a physician and a human being.  Don't get me wrong...I'm not saying that those who are doing those types of practices are less of a physician or a human being...I am giving kudos to all that are in the health care field for doing what they are doing, however they are doing it.  All I'm saying is that I'm choosing to jump off of a moving train that I see will be going off of a steep cliff into a ravine.  Life is too short for me to regret not taking the high road.

Doing both of these options, in my opinion, would only affirm the inequality and the inefficient US health care system and perpetuate the ills of the system.

I've taken my practice as far as it can go without abandoning these core beliefs.  I guess I'm pretty passionate about these beliefs, and I will not sacrifice them just so I can give myself the illusion that everything is just fine.

I also know that there are people and doctors out there that share the same values but their voices are not heard (I'm pretty sure most are not speaking out or being heard, otherwise, I wouldn't be complaining!).  I suppose that's what this blog was about, to share my story to others, for those who are willing to listen.

Friday, June 15, 2012

A Perfect Storm - the third ingredient

The third ingredient is the lack of universal health care coverage for all Americans.  Again, I've harped about this in my blog.  Although the direct effect on me is less obvious, the effect on my patients is tremendous.  I've lost patients, not because they did not value my care or feel that I was an incompetent physician, but because they lost a job, can't find a job to pay for insurance, don't have money to pay for their deductibles, or their employer is struggling to pay for health care coverage and have to switch to new insurances every year.  Sometimes they switch to an insurance that puts my patient on a different network so I can't see my patient anymore.

Why does my relationship with my patient need to depend on whether they have a job, have money, or what kind of insurance they have?

Some advocates of this current system and those that say no to universal health care or "socialized medicine" say that patients have unlimited choices as to which doctor they want to have a relationship with, so why rock the boat?  My response is that all of my patients, at some time or another, unlucky or otherwise, do not and may not have a choice.  It's an illusion of choice because that choice can be taken away by circumstances beyond their control, no matter how prepared, rich, successful, or educated you are.

I know, because, I too have been a victim of this system.  Being a business owner, you're on your own regarding health insurance for yourself and your family.  Thankfully, I made enough to pay for insurance, but only the kind that is catastrophic (high-deductible).  When my wife was pregnant with my son, we consistently paid our dues on time and then on the day that my son was born, we found out after we came home from the hospital that our insurance company dropped us from the plan for not paying the previous month's dues.  We found out later, that even though we sent our payment on time, our insurance company already decided to send us a letter warning us that they would drop our insurance for failure to pay (while my wife was in labor, mind you), even though the due date hasn't even happened yet.  Subsequently, we were given a nasty surprise by the hospital that we weren't covered even though we thought we were.  Although the insurance company acknowledged later that they sent the letter in error, we had to undo the damage in reconciling the immense hospital bills that were sent to us because of that error.  And although we knew how to get ourselves out and knew the system and the games that insurances play, we were able to minimize the damage.  But mentally and psychologically, the damage was draining for our family...adding more stress where we could have spent quality time with our children.  I can imagine that our example happens quite often and how many people fall victim to the system and can't get their way out.  Obviously, being a doctor did not keep me from being immune to the system.  It was very humbling for me to experience what some of my patients had to deal with.

All the more that this system has to change.  Simply, for me, health care coverage is a right for all of us; whether you have a job or not, whether you are a child or retired, whether you are male or female, whether you've been ill before or not.  Everybody in, nobody out.

From a solo physician perspective, there are benefits to a single payer system; it would be much easier to work with one payer than hundreds, one set of rules versus a hundred set of different rules, etc.  With Medicare going to Medicare Advantage Plans several years ago, it went from one payer to many payers and it got so crazy for me that I had to drop Medicare altogether.  Not only did the change made it crazy for me, my patients had to re-apply every year and they couldn't tell heads or tails which plan was best for them (actually, none of them, in my opinion).  I think we all have better things to do than deal with our insurance.  No wonder most of our young adults don't even bother getting insurance.  Until something happens to them...

A Perfect Storm - the second ingredient

And that would be The Games Health Insurance Companies Play.  Again, my previous blogposts have covered this landscape with examples and details.  However, and this is just anectodal to me, the ways these games have been played have gotten worse recently...maybe because they see the writing on the wall with healthcare reform not necessarily going their way (yet...).

First, to preface, I have no problem with what insurance companies are.  If they are for-profit entities and they are beholden to their stockholders, their mission and their existence is clear.  What is NOT clear is the ROLE that they play in the HEALTHCARE SYSTEM IN ITS ENTIRETY.  What is clear to me is they have wedged themselves been the doctor and the patient and holding the money that is the transfer of payment for services rendered by the physician.  Aside from the payment formula disparities and lack of prioritization (See Ingredient #1), the doctors are beholden to what an insurance company will pay them for any services rendered to a patient.  These are what I refer to as the Games Health Insurance Companies Play.  There are several games I'd like to highlight that us physicians, whether we know it or not, are unwilling participants and ultimately the perennial losers in these games.

1.  The "We won't pay you because we don't know if your patient is on our insurance or not, and oh...we don't have that information yet..and we won't pay you anyways" game.  There's always a disclaimer when you hear the voice messaging system when you call the health insurance companies that they cannot guarantee payment of services based on the information they're going to tell you about eligibility for a patient.  Ever wonder why?  Because at any moment's notice, something may inexplicably change, without knowledge of the patient or to the physician or to the employer (if it's employer based) and we're at the mercy of whether the insurance company ACKNOWLEDGES that a patient is eligible.  This is even worse when it comes to secondary insurance; then it's another game of....

2.  The "The OTHER insurance company is paying it first" game.  And it goes back and forth, back and forth.  Payment, anyone?

3.  The "I want my money back" game.  Because of the first game, or the second game, or for some other lame reasons because they didn't know their own rules.  It's a total time waster, and a waste of resources.

And for the patient's point of view...the following are games that I'm very upset about.

4.  The "We're gonna make your doctor's life hell so the doctor will never want to order another test again" game.  I understand that some procedures and tests are very expensive and will need a review.  But by making the whole process to get authorization a total time waster for the doctor only so that the doctor will never want to deal with them and think twice about ordering an MRI (for instance) for where there are already standards and guidelines that we're taught over and over again.  I do not find it useful for an insurance company to have me wait 30-60 minutes on a phone to get a human person to tell me that I followed the guidelines and they're going to grant it anyways, and to also personally denigrate you on the phone after you've already met the guidelines and then tell you that your an incompetent doctor because I care about my patients and actually listen to them (by the way, that truly and shocking did happen to me).  I keep doing it anyways, but knowing that I lost 30-60 minutes of my time doing this.  When you start adding it up, it starts becoming a reality that they don't care about my time.  They only care about their profits (which I guess they are entitled to) but this is exactly where the SYSTEM is all wrong.  Take the profit motive out of it and we'll already be in a much better place.

While on this note, I will say that I understand that the government (and rightly so) wants to crack down on fraud and unnecessary testing.  Of course, the government is beholden to the people.  The motives of insurance companies are not so clear cut, and at its worst, greed and maliciousness are part of it.  But I can say that if we fixed ingredient #1 and made it less of an incentive to commit fraud for expensive procedures, hospitalizations, etc; we wouldn't necessarily be in this mess to begin with.

5.  The "You have to pay more for health care services and we keep more of it anyways" game.  Not too long ago, people only had to pay a small copay for their visits.  Now we're dealing with hundreds and thousands of dollars of yearly deductibles before an insurance company is paying a penny for services.  What's the point of having insurance if you can't pay for these deductibles anyway and you're still paying the insurance company money to have "health" insurance.  So many of my patients can barely afford to pay the deductible amounts.  And then to lose your job, you're really stuck, even with COBRA coverage.

All these games, to me, are an insult to what should have been a simple, common sense transaction for services between the patient and the physician.  What is a viable alternative?  A single-payer system where everybody's in and nobody's out coupled with priority of services to preventative care and fair pay for primary care providers.  None of these games are played in other countries with single payer program or universal health insurance.  When I tell some of my peers in other countries about my experience, they laugh, take pity on me and they think we're a bunch of suckers.

Alas, that is where this second ingredient did me in...I saw no hope in the next decade that this was ever going to change given the political climate we're in.  Worse yet for me is this simple fact...THE HEALTH OF OUR PEOPLE IS NOT A GAME.

Wednesday, June 06, 2012

A brief interlude - my story

I will give a *brief* history of how I started in this profession and what has influenced me over the years...just so you know a little about me.

My first memory from my childhood that made a lasting impression, of all things, was listening to the music of the Beatles. Their music was special and enchanting. I also remembered the assassination of John Lennon when I was in Kindergarten - I got to know much about John Lennon and what his music meant to many people as I was a young kid in elementary school; "Imagine" was the song that epitomizes what I think John really felt about humanity and the world. As a child and adolescent, it made a whole lot of sense to me...even now.

As I was learning about the Beatles and their influences, I recalled their discovery period when they visited India and that was where I became aware of Mahatma Gandhi. Also, the movie starring Ben Kingsley got me interested in this mysterious figure who happened to promote change through non-violence. Then I read about Martin Luther King, Jr who practiced Gandhi's concepts. Again, I thought that was such a cool idea; the concept of change and non-violence was my guidepost to what I did in life.
It was too bad that all the individuals I admired so far, they were all assassinated at their prime. In some ways, I was unusually fascinated with the concept of martyrdom as a child.

I grew up in a family that worshiped Buddhism. I also attended Sunday School at the local church and they all seemed like good ideas with the exception of the idea of organized religion (for both) - I also began to have an inkling of what group mentality was and that it wasn't such a great idea when it went too far. I was influenced by a book I read in junior high, The Wave, by Todd Strasser which talked about how powerful group pressure can be. There was a time I was agnostic and not committed to any type of religion.

I was enamoured by Albert Einstiein, both as a scientist and as a person. Not only could he think of great physics concepts to explain the ways of the world, he was a great violinist too! I got into computers very early on. Commodore 64, Apple II, Atari 2600, IBM...I knew the ins and outs of 1's and 0's. I created a video game out of machine language.  I also played the violin (I started playing before I knew that Mr. Einstein did himself) and played in a variety of string orchestras and jazz ensembles (Jazz with the violin??  See the Turtle Island String Quartet).

High school was in some ways challenging for me. I couldn't get hired by the local grocery store as a bagger. I couldn't get hired by McDonald's...pretty pathetic for looking at a part time job. Then I got hired on by a local bakery/cafe in St. Louis called the St. Louis Bread Company and I sold bakery goods and made soups and sandwiches which at the time was a fledgling anti-fast-food phenomenon. Just when I was graduating from high school and offered my resignation, the company was bought out by a California group of investors. People will know this local company by it's now corporate name, Panera Bread. But back then, I realized the importance of a local economy and how important I was, even as the lowest member of the totem pole, in this local company. I even saw how computerization of certain repetitive tasks (touch screen cash registers that was called the Micros system) made operations efficient, less error-prone, and made statistical analysis of items that sold well versus others that didn't...it was cool, even back then.

As this was going on, I was following the footsteps of my father as an engineer. And then...

A near-life-threatening scooter accident right after high school graduation in Taiwan started me truly thinking about what was important to me in my life. It makes you take stock of who you are as a person, what you can contribute to society, and how you can make a positive difference in even on person's life...all from this pivotal event.

I realized I only had one chance in this life to do what I really want to do; I had the choice to make and only I could make it once. I could no longer imagine myself sitting in a cubicle looking at diagrams all day long. I needed more to fill my urge to help the people around me. It had to be personal for me. But yet, I still had the scientific side that I appeared to excelled at. Thus, I chose my path to be in medicine.

I was influenced by a family doctor (too bad I didn't know his name) that spoke at one of the seminars for pre-med students at the University of Illinois where I went to college. I remembered how passionate he was about taking care of the whole person, not just the specific body part or medicines they prescribe to "fix" people. I read into this concept and put it into my letter to admissions when I was applying to medical school. And then I got in to the University of Missouri.

Medical school was like going through military training. I was poor. I lived in a cockroach infested apartment with a broken air conditioner in the sweltering heat. I ate at McDonald's nearly all the time and I felt icky all day long (see Super Size Me and you'll know what I mean). During this period of turmoil, I read a book that happened to be lying on the table at the school library called "Small Is Beautiful - Economics as if People Mattered" by E.F. Schumacher. First of all, I wasn't even remotely interested in the theory of economics (didn't take it college, any financial topic was gibberish to me, didn't know the meaning of debit and credit...), but somehow the title grabbed me.  It talked about how the theory of modern economics is irrational in that there was not an infinite amount of consumption and that humans have to know what is "enough" - the concept of "enoughness" and NOT "bigger is better" and "greed is good". The concept of Buddhism Economics was from this book and it propelled me to read more about Buddhism (specifically Zen Buddhism) as more as a philosophy and a way of life, rather than organized religion. During medical school, I also managed to fulfill a dream of mine to be in a rock band.  I got to play a whole bunch of songs from the Cure, U2, Eric Clapton, Kiss, The Eagles, and The Police (but sadly, never the Beatles).  Through that outlet, I got to let out the steam and frustration of being in school.

I also felt like I took a time space warp when I entered medical school. Everything was still documented by pen and paper. Charts upon charts - "can't find the chart" - and the obligatory hand cramps. It's crazy that this still existed when I saw how the St. Louis Bread Company could use a touch screen ordering system 8 years before?! Being a self-professed computer nerd, I was totally flabbergasted and perplexed that this was the new reality.

Looking at residency programs after medical school, I got to visit Seattle for the first time after living in the Midwest all my life. I happened to be staying at a local youth hostel (no hotel rooms were available because of the WTO conference that year). This youth hostel also was Ground Zero for social activists who were protesting at the WTO conference that ended up in violence with sound grenades, curfew, tanks and smashed windows at the Bon Marche department store. I was getting all kinds of education about fair trade not being free trade, the pros and cons of the North American Free Trade Agreement, local and sustainable practices for the economy, ecology, and the environment.  It opened my eyes to a whole new way of thinking about society, people, and the impacts we have from small to large.

After all that traveling, I ended up doing my residency in family practice in Minneapolis, Minnesota. I thrived there, taking care of the indigent population that consisted primarily of immigrant and Hispanic/Latino families. I also delivered quite a few babies during that time. I also learned more about complementary and alternative medicine. I also helped the hospital acquire an new electronic medical record system (finally!). It was everything I considered family practice to be. I also became quite aware of the problem of economic and political forces that steered students into specialty practices rather than primary care. I recognized then that family practice clinics and physicians were slowly being steamrolled into this larger byzantine system that encouraged increased procedures, increased overhead, increased patient numbers, but less time with patients, less quality of care, less connectedness to the people we serve. Everything was getting bigger and the family doctors were becoming cornered into a wall. It was as if we had no choice but to follow the status quo. Talk about peer pressure (ie The Wave).

And when I finished residency; I made a choice to take the road less traveled. I took the approach of what was small was beautiful. I centered my practice after the whole concept of whole person/whole family care. After a false start and a broken promise after 8 months, and then making a decision to fully go it alone, I have finally made my dream come true...a micro-practice that I built along with my wife. I was fully utilizing computer systems to help me streamline my operations so I can still do all of the things that computers cannot do - like diagnosing an illness, healing hands, the art of medicine, making agreements with my patients; it was recognizing the limits and ultimately creating a unique but natural balance with the way things work. Granted, it was still hard work and I didn't get paid much, but in my own way, it was the most gratifying type of work I can imagine for myself.

Now...back to the the perfect storm...

A Perfect Storm - the first ingredient

So where to begin...what caused the demise of my practice was essentially various factors and elements that led to a perfect storm.  I'll blog about each one of these elements from one posting at a time.  Some of this, if you've been reading this blog already, may be old news but I'll figure it may be good to revisit them.

The first and important factor is physician pay for primary care physicians like me.  As you can see in this graph, this is the layout of average salaries for physicians in different specialties.  This was discussed to some degree in this blog post on KevinMD.

We must redesign our health care payment systems to value primary care

Now you're saying, "That doesn't seem so bad...", but keep in mind this is an average.  And most family physicians are in group practices and are subsidized by their parent organization (hospital, multi-specialty groups) to cover the budget loss due to insufficient reimbursement for primary care physicians.  The other part that is also not seen in this graph is that for most family physicians, to keep up their end of the deal to be a part of these larger organizations, is that they have to see more to get more.  It's still not enough, but it's better than nothing.  What happens when you see more in a finite amount of time?  Less time with patients.  I learned about this perverse system more than 10 years ago in residency and all I can say is that this has not changed at all.  In fact, it's getting worse.

Stepping back, and looking at that graph, wouldn't you agree that if we were to truly talk about preventative care and prioritizing the health of our children and young adults, shouldn't this graph be a mirror image?  In my opinion, our health care priorities are not in line of what we know to be true.  I understand that doctors who do very risky and complicated procedures should be compensated duly for their education and the work that they do, but at the very least, shouldn't we be prioritizing the work of primary care physicians who try to keep patients from being in a hospital, keeping them from major procedures to prolong their life due to easily preventable lifestyle changes and other less costly interventions?  Is there not an investment in keeping people healthy rather than spending billions of dollars on futile measures?  Wouldn't we be saving money as a society rather than paying more for things that do not provide an investment in the wellness of the society starting with children?

Think about it...

Tuesday, June 05, 2012

The End...starting from the Beginning

As of June 30th, 2012, my practice will cease to exist.  For those who did not know, in short, I am a family physician practicing in Portland, Oregon for the past 10 years.  My practice was unique in that I  had no ancillary support staff.  It was just me and the patient.  When the patient calls, it is me who speaks with them.  When a patient walks in the door, it is me who greets them and sees them from start to finish.  Most times, I spend 30 minutes with each patient, sometimes up to an hour.  I've been using electronic medical records ever since I started.  I use technology to cut through the clutter and to efficiently get the tasks I needed to get done for my patients.  The technology was nearly invisible to my patient...the primary value of the visit is the face-to-face time that I spent with my patients, the eye contact, listening to them, provide education, and help them.  It was my dream to practice this way...the way I thought the practice of medicine should be.  I left what was the status quo of hamster-wheel medicine to pursue my dream nearly 10 years ago and I spent 10 years perfecting and maintaining this dream.

Only to see my dream be on permanent life support with no end in sight.

Due to circumstances beyond my control.

Like making a heart wrenching decision to pull a patient off life support, I had to do what was right for me and for my patients.

What happened?  I will explain in the next few posts....