It's "Burn Your Health Insurance Bill Day!"

Today, March 11, is the day to voice out your support for single payer health care. I would certainly like to burn my health insurance bills; unfortunately, my clinic operations depend on it (for now), and I would be creating a large amount of carbon emissions with the bonfire. But, in spirit, I have copies of PDFs on my laptop that I plan to stuff in the recycle bin and vaporize with a button, repetitively. The word needs to get out and Obama needs to hear what the majority of Americans and physicians and nurses all desperately want to see change.

Oh...the drug companies!

You can definitely where things go from here, and the true motives of pharmaceutical companies, when all is on the line on the stimulus package. The drug companies are insistent that government funding for research to see if the drugs really work is a bad idea. We're probably going to see a lot more this as we are finally bringing up issues that really matter.

Muffled

I recently read an interesting article about a BBC documentary that was only shown outside of the US about the state of the US health care system. Pretty shocking stuff, but I'm not actually surprised.

The tube

Wow...on January 14, 2009; while I was flipping channels on my TV (local stations with ABC, CBS, and NBC), literally every single commercial break was filled with at least one pharmaceutical direct-to-consumer advertisement...Crestor, Viagra, Humira (for rhematoid arthritis), Boniva, and others.

I admit, I don't watch TV every day so I may not have noticed the trend; I know at least 5 years ago that's when it began...but every single commercial break??!

All I can say is..."wow".

Like my observation that health insurance is starting to pinch pennies mercilessly over the past year; I'm beginning to wonder if the pharmaceutical industries are doing their last "hail Mary" before their Golden Age is overwhen Obama takes office...if and when that happens.

Of course, I just giggle at the absurdity of these commericials - 90% of the time devoted to it is talking in quick talk about all the potential side effects these medications have - like if someone was really listening in, they would really want to get sick from all of these medications! Literally, who are the marketing geniuses for these companies?!

Recommended viewing

I have included a link to a recently made video that wonderfully and explicitly details the issues surrounding the American health care system today. The ideas presented obviously coincide with my sentiments and my views and hopefully, more and more get to learn and hopefully assist in a political change to make single payer health care a reality.

A good primer

This document is actually a very condensed and informative primer on the American Health Care System, how it came to be and where we go from here. Happy holidays!

Measuring happiness

Now this is a cool idea.

Squashed

As we wait, if and when health care reform is a reality (or what it would look like), I can't help but notice the external forces that are affecting the landscape for solo practitioners like me, currently, and in the future as the wheels keep turning and time is ticking. Below are some examples that highlight some of what I'm worried about.

1. CCHIT, also known as Certification Commission for Healthcare Information Technology (who comes up with these acronyms, I don't know...but as you'll see later, it's quite fitting for what kind of mess this is). It was a great idea on paper...to have an agency that sets standards for electronic medical records with the aim for interoperability and allow secure exchange of medical information. However, as it quickly evolved, it has become a sore spot for me as the $COST$ of being certified as a CCHIT product no longer becomes reasonable, especially for us smaller doctors that don't that have much overhead to negotiate without affecting our day to day operations. What bothers me is...why do they (CCHIT) have to be some agency that requires that an EMR company to pay them a substantial amount (I believe it's around $30,000 for the initial 3-year cert and then $5000 every year in the 2nd and 3rd years to cover licensing fees). That's a HUGE burden and that cost gets passed down to the physicians/hospitals/etc who are purchasing these products! As someone who also dabbles with computer software/programming (I'm actually a supporter of open-source projects), I see "standards" as a set of guidelines that in order for other systems to work or connect or to meet a minimum level of acceptability for user-friendliness...a good example is the W3C (World Wide Web Consortium) that determines the standards for HTML code for website that get translated by Web browsers like Mozilla Firefox...there's NO huge cost layout to make these standards established and for other computer software companies to comply if they want to be competitive. This is yet another example of how the cost of *anything* that is related to health care is so absurdidly high for no real, substantiative reason other than the profit motive. I mean, to get a "medical" stool costs 5 times as much from a medical vendor than it is to get from Costco (just a different color). What's the reason for that?! (and I hope it's not that the dyes for vinyl covering for the medical stools comes from some special factory that uses gold screws).

Anyways, pretty soon, Medicare has plans to make sure that doctors are using these certified EMRs and electronic prescribing. That too, on paper, sounds like a good idea...it would be great if health care finally uses electronic methods to input, store, and analyze data...like the banking system has been doing for, what, 40 something-odd years? But who's gonna pay for this? Why pay for some "standards" that have no benefit for me when I pay the EMR company who has to shell out this money to this agency to create the standards? Does it help me in any way?

I'd rather pay an EMR company to create a excellent product on its own merits and not have to up their price just to be certified. Oh, by the way, I do have that right now. I use Amazing Charts...but the bad news is that they held out for so long not having to be pressured to be certified. However, with the inevitablity of Medicare mandates, they have now made the decision to become certified, and (guess what?), the cost of their EMR is now 10 times more than when I purchased it including the annual fees for updates. YIKES! So I'm actually trying to shore up a way to create some HTML/PHP templates for OpenEMR...that's what I do in my spare time these days...at least the EMR is free.

I don't really know what I would offer as a solution; I think there's definitely a developed culture of "If it's medically-related, it's gotta be expensive. Let's offer a product to doctors and because they have lots of money, we can up our charge for the same product that we sell to others, but let's don't tell them that." Yeah, well I'm rowing up CCHIT creek because I'm not one of those well-paid doctors.

2. Vaccinations - a nightmare of epic proportions for me. Let's say you're a clothing store and you order your merchandise from the manufacturer for $10 an item. As a store, you need to increase the charge cover the cost of your operations, so you bring the total to $20 and that's the asking price to the customer.

OK, so now let's say that instead of the customer paying for $20 item, he/she uses their grandmother to pay for the item and the grandmother says, "I'm not going to pay for this item for $20, I'll pay you $5". What would the store do at this point? The store would say, "I'm sorry, that's how much we charge".

OK, so now let's say the vaccine manufacturer is our manufactuer in this example. The store is the doctor's office, the customer is the patient, and the grandmother is the insurance company (I mean no insult to grandmothers). Right now, the store would say, "OK...I'll give you the item, you pay me $5 dollars, and that's that."

I don't know how medical doctors and offices got into this (I think I know, we're probably too nice or maybe back in the day, we didn't read the fine print) but no self-respecting business person would even consider this a fair deal. It's a raw deal.

So you've got these mandates (again). I'm generally a believer in vaccines (but there are some caviats to some of the more recent ones, but I'll discuss that later) and there's a huge public health benefit for vaccinations. It sounds good on paper but the devil is in the details. The system is rigged so that in the end, doctors are losing money to give them. This is highly magnified in a smaller practice, hence the argument that to absorb the loss, you have to be in a bigger group. But why does it have to come to this? All that I ask is that the cost burden be fair, starting from whether the cost of the vaccine is justified, to making sure the insurance companies are actually paying the cost of the vaccine if the manufacturer is asking for that cost so that us doctors aren't left with the bill.

There are victims I see amongst some of my colleagues, too numerous to count, that have been so frustrated with this system and dealing with programs (Vaccine for Children's programs for the uninsured or on Medicaid) that try to aid because it's so unfair. We're literally at the mercy of money-hungry entities that believe you're well off and can be bought off and sold off; but there are no alternatives; no regulations.

3. A very well-written blog about the concept of "overtreatment." I second all the statements!

Perhaps a little light from a long tunnel...

What a difference an election makes - it's all about dumping far-right, far-left ideologies and really address the issues that affects everybody today and now insurance companies are wanting to play ball as along as everyone is covered!

Speaking of which, this is an excellent summary on the plight of primary care. Again, more of the same but highlights the struggles and obstacles to improving our health care system. As I read this, I was reminded of my experience as a 1st year family practice resident at Hennepin County Medical Center in Minneapolis, Minnesota nearly 8 years ago and one of my esteemed preceptors, the now retired Dr. Harley Racer, talked to me about how I only get 15-20 minutes with a patient after I had spent nearly an hour talking to a patient who had diabetes, hypertension, liver disease, and tobacco use and managing the myriad of issues (sound familiar to other family physicians?); I certainly understood his position that we were working within a confines of a messed up system, but he encouraged me not to give up hope; that we went into medicine for noble, selfless reasons. I saw in his aged eyes, knowing that he participated in being a general physician since the 1940's, that he'd seen a world that has changed before him. I never forgot that lesson and I carry it with me to this day. Perhaps, with perseverence, there can be a light at the end of the tunnel.

Grumblings

As I scan through the various medical blogs since the election, I see an emerging civil war between specialists and generalists erupting from various proposals from policymakers, such as Senator Max Baucus from Montana. In order to fix the U.S. health care system, addressing the plight of primary care physicians is absolutely essential. What does that mean? For some, it's "spreading the wealth" in regards to income distributions between specialists and generalists and that strikes fear into the hearts of specialists who have depended on the decades long payment system that favors procedures versus investment in prevention. There's also stuff of sorts that primary care physicians don't work hard enough and we have to see more to make ends meet. Heard that before. When we cut through the spin and fear-mongering; the essential question is this:

Are we as a society going to understand and redefine what it means to have a health care system that actually values health? Or are we as a society going to believe that the direction we have been going is the best that we can do? Now, come up with your answer....

I've also read other weblogs where physicians are absolutely horrified by the prospect of a single payer system that the current examples of Medicare and Medicaid are going to spell doom to the health care system as a whole. Yes, if Medicare and Medicaid were the only payers in this nation and working exactly the way it is right now, I would be awfully afraid of what would happen to our healthcare system. However, in response to that concern, I propose the following.

Call me an optimist, but there have been numerous periods in American history that when there is a calling and we have an inspirational leader, we can acheive great things together. Franklin Delano Roosevelt and the New Deal and the defeat of Nazi Germany and Japan; John Fitzgerald Kennedy and taking the man to the moon; Lyndon B. Johnson and the Great Society. If we can do that then, how come we cannot acheive a perfected health care system for all, starting now? The great start, which I'm glad that President-elect Barack Obama stated in the debates, is that health care is a right for all Americans. And I think most people will agree on this now. Not too long ago, that was not the case.

Lately, over the past 30 years or so, we have not had the gumption or clarity to take us where we need to go...and just like someone who has not yet understood the importance of change because there is lack of awareness in the problem (alcoholics, for example), perhaps the most of us in the U.S. were led to believe that our system is the greatest and infallable in all the world. We've all heard in some way, shape, or form that our health care system is the "greatest in the world", and it's all because it's not "Socialized" medicine. Peel away the layers and over time, the symptoms of the illness we call the dysfunctional health care system shows through. The growing numbers of the uninsured. The hurting businesses trying to pay for health care for their workers and losing competiveness around the world. Our fallen economy. Mounting health care bills for families. Overflowing, overburnded, burnt-out emergency rooms, urgent care clinics, and primary care clinics. Rural clincs struggling to stay afloat. Medical students, wanting to do primary care, but with financial burdens, deciding that the wise thing to do is to be a specialist. The cycle feeds itself and leaving destruction, anger, frustration, and fear in its wake. And the results show. The "fundamentals" of our current system are misguided, bordering on unethical (in my opinion), overly complex, and highly counterproductive. These fundamentals are then fed and supported by fear and greed.

Right now we are peering down the chasm of this so-called illness and wondering, should we just continue to ignore it and pretend that it will just go away, or shall we face it and confront it?

Once we make the awareness, which believe we are at this junction (it's long over due, in my opinion), we have the capacity to start change and work together with a committed goal. Going back to my optimism statement, I believe that we have so much untapped potential - all of the current health care workers, those who work in our clinics, hospital, and yes, even the insurance companies, that can be channeled into this endeavor to look at our system with fresh eyes and renewing a commitment to care and quality for all Americans; look again and what it means to have "market-driven" medicine and focus again on what is good for all rather than just for a priveledged few. This is the stuff that's happening in the grassroots right now, in Oregon.

Imagine if this can spread to the rest of the nation. I can see, from our nation's history (I'm kinda a history buff), that we can have great ideas and great people - coming from true intentions that exemplifies the common good. Just look at our attempts to bring a man to the moon. We poured our efforts into education in math and science with true competition, not out of greed, but for the goal of space travel.

What I see is that we can have a system of health care that balances the independence of physicians and patients, taking the middlemen of payment out and consolidating it to the largest insurance risk pool (national insurance) and where the responsibility of the management of the risk pool is dictated by the mandate of the people (taxpayers and those who vote)...and where doctors no longer have to be torn between the triangulation and really focus on delivering quality health care (this is where my passion is!). What does that describe?

Single-payer health care.

Ahh, but do we have evidence that this works?

Yes, we do...think of all other industrialized nations in this world and everyone else has shown that health outcomes have generally improved when there is a unified, single-payer health care system (there's different variations, but all variations on the same theme, where everyone is covered). We may argue that the United States can choose to be different (like who else in this world use the English or Imperial system for measurements and temperature rather than metric?!?!...but that's another diatribe for me), but the cost of choosing to be different far outweights the benefit of making a smarter choice.

So, this is what I would say about the whole topic. Learn from others and learn from history. Use the links above to be the starting point and guiding light to get to the answer. Don't just take it from me, but maybe we'll all end up agreeing. Now that'd be nice, wouldn't it?

Hope, maybe?

I'm so glad the election went the way it did. Now, the hard work begins. Recognition of the problem is step one and that begins with more mainstream media attention being paid to the plight of the primary care physicians. The reason? Much that has been said here in this blog. Hopefully, the solution to the health care crisis will involve the recognition of the work of primary care physicians - prevention, education, and bringing back the meaning of health in "health care".

Well said...

In these tough times right now, we must take perspective of our view of this crazy world. This editorial below by Norman Solomon succinctly and clearly makes a claim for "waking us up" and taking perspective.


Published on Tuesday, September 23, 2008 by CommonDreams.org

Too Big to Fail and Too Small to Matter

by Norman Solomon

These times provide a crash course on the corporate state:

If a company like AIG is too big to fail, the government will rescue it. Mere people -- too small to matter -- are expendable.

The insurance industry is too big to fail. A person's health is too small to matter, so -- when it fails due to the absence or loopholes of insurance coverage -- that's tough luck.

The Defense Department is too big to fail. The people it's killing in Iraq and Afghanistan are too small to matter.

The U.S. nuclear arsenal is too big to fail. The Nuclear Non-Proliferation Treaty, undermined by Washington, is too small to matter.

Overall, the warfare state is too big to fail. The virtues of peace are too small to matter.

Agribusiness is too big to fail. Family farmers are too dirt-small to matter.

The leverage for the U.S. Treasury to subsidize Wall Street is too big to fail. The leverage to subsidize mothers and children kicked off welfare is too small to matter.

The political momentum for bailing out corporate America is too big to fail. The political momentum for funding adequate payment rates from Medicaid to reimburse healthcare providers is too small to matter.

The oil conglomerates are too big to fail. Global warming is too small to matter.

The prison industry is too big to fail. The need for preschool is too small to matter.

Corporate power is too big to fail. The ordeals of working people and want-to-be-working people are too small to matter.

Human worth as maximized by dollars: too big to fail. Human worth as affirmed by humanistic values: too small to matter.

The current odds of pumping at least several hundred billion taxpayer dollars into corporate America: too big to fail. The current odds of launching a massive federal jobs program: too small to matter.

Such priorities and mindsets are in overdrive at the intersection of Pennsylvania Avenue and Wall Street. But a basic shift in government priorities is possible. That's what happened three-quarters of a century ago, when a progressive upsurge prevented the re-election of President Herbert Hoover -- and then effectively mobilized to pressure the new occupant of the White House.

After campaigning in 1932 on a middle-of-the-road Democratic platform, Franklin Roosevelt went on to become a president who denounced the "economic royalists" and made common cause with working people and the unemployed. People across the country organized for social change. In the process, you might say, the power of progressive movements became too big to fail.

Something like that could happen again.

Little empathy

I came across a recent article on the Archives of Internal Medicine which struck a chord to me. Actually, I'm not really surprised since I have had concerns of this since I was in medical school and the emphasis on training for the "science" of medicine and the lesser emphasis of the "art" of medicine. I came in naively to believe that there is a balance to both. I still believe in that balance but the training for new medical professionals as well as the emphasis of over-specialization has definitely tilted to the point where we now see doctors no longer having that empathetic skill to connect to their patients. Even more striking is with the recent tide of "market-forces" and "letting the market decide" for medicine is how people are just treated like commodities and widgets - it's pretty sobering...whatever happened to real interaction with real people? It's definitely lost in translation with all the hype of the cure-all pharmaceuticals and state-of-art technology. *Sigh*.

A sorry state of affairs....

More bad news on the horizon - not much of a surprise as this trend was going on since I started medical school in 1996, however, I feel that the backbone has broken and the demoralization of primary care has, in essence, become the end result of the reliance and emphasis of overspecialization, supported by the the Medicare payment schedule equations and de-valuing of primary care visits in general.

This is nuts!

Just had to put this link on my blog as it completely astounds me that there are individuals to this day that believe that the healthcare crisis in the US can be solved by abolishing the "uninsured" term in the census and use the ER as the solution! The actual blog by John Goodman gives more details on this *ingenious* solution; which by the way was also the same solution George W. Bush suggested several years ago. As you can see, I'm all about single payer health care - it's really the only solution that makes sense from every perspective - for the patients, the physicians and health care providers, and the community.

Holidays (a late post by the way!)

I'm sitting in Illinois on a December day, writing this blog with the intention to reflect about this past year. It's been a steady year in my practice and I still remain committed to my vision about my practice. Overall, in the past 3 1/2 years since the inception of my practice, I believe that this style of practice is still viable...at least for me. Perhaps that's all one can really ask for, to find something that fits, even if it doesn't fit everyone. Here are my thoughts...

1. I am more and more concerned about the health care system of America. Every aspect of the deficiency of this system affects my practice but most of all, my patients. Things I have discussed before - such as the fragmentation of care, minimal value placed on primary care physicians, over-utilization of emergency rooms - all continue to be a trend that does not seem to be reversing. Every year, Congress is always threatening to decrease compensation to physicians but when reimbursement to primary care is already at the lowest tier, the very existence of primary care is threatened. There is so much talk about the need for preventative medicine, and a medical home but I'm concerned that it may be too little, too late. Will the upcoming election in 2008 focus on this important issue? I hope so, at least there's talk about it now...it's just a matter if there is enough people power to overcome the huge medical insurance and pharmaceutical industry juggernaut. There is only a few presidential candidates that are willing to fight it, however.

2. Insurance companies are become more cunning about saving money and increasing work for physicians for what purpose? As I see this happening, I can surmise one thing...the tide is turning about their clout and the insurance companies are feeling it and milking everything it's worth in the health care industry dollars. And why are physicians complying with this? I know I'm just as guilty as the next doc but I'm thinking more and more about ditching this system unless some meaningful change exists (see #1)...which means the attractiveness of a cash only practice is looking better to me every day.

I recall a moment in my medical school training when I was doing a rotation in rural medicine in Rolla, Missouri. I was following an emergency room doctor at 1 in the morning seeing patients. During a lull, he sat me down and drew me a diagram of 2 boxes, one box being the patient, one box being the doctor. He mentioned that the connection between the 2 boxes, just like any other relationship, is important for both involved. The relationship is jeopardized, however, when a triangulation occurs between the 2 parties. This is the middleman, the insurance company. And as this third relationship evolves, which began to develop after WWII in America, the less the 2 initial parties began to see eye to eye. Just like Machiavelli, the role of this middleman, in another level, is dividing and conquering. They have succeeded and thus the role that they play now, politically and culturally. Now more than ever, any fear about the decline of this middleman is parlayed as threat to the doctors - "You won't get paid!" and to the patient - "You won't get good health care!" and who wins? What other industry works like this? Perhaps my previous work as a cashier in a bakery/restaurant highlighted this; how absurd this system has become. Over the past year, I've been more in tuned to this absurdity...and it has colored the choices I have to make as a doctor about my future.

Finally, an update...

Finally, I'm ready to do another update (hasn't it been more than a year?!). It's been a crazy year so far in my practice...good for some reasons, not so good for other reasons, as it is with everything in life. Anyways, just a little blurb on something I recently read about "noncompliance", which I found to be an interesting perspective; something I will occasionally need to remind myself on how to deal with...

More on my mind...

It has been a long time since I posted but there has been a lot on my mind lately. There have been some issues that have come up that will impact my practice in some way down the future. Some are good, some are bad. There have also been some really absurd things that have come my way lately, most of it makes me wonder about the state of things in the medical world.

Firstly, there was an instance where a patient needed a prescription for generic Wellbutrin for depression. According to my Epocrates, which I use quite often for insurance formularies, it was considered a preferred medication on her insurance plan. However, I got a call from the pharmacy that they needed a prior authorization. Confused, I called this pharmacy benefit manager for her insurance (which had apparently changed without any notification). While I was waiting for 10-15 minutes on the line to talk to a person, the message mentioned that there was a website that they said that I could use to do prior authorizations online. So, I fired up my web browser while I was on the line hoping to see what the situation was. Of course, the website then tells you to do prior authorizations, you can send a letter or by telephone (not online!). Then, their formulary was not up to date because they still state that the medication was preferred. Finally, I did get to speak with someone who had made it a point that he had to create 2 separate cases because I had to request a medication that needs prior authorization as well as a quantity limit override. Then he transferred me to a pharmacist who apparently is the one who determines whether to accept my request or not. The question I recieved was, "Is the Wellbutrin being used for smoking cessation?" My answer was no. My next followup answer was, "Why does it even matter?" I know that health insurance companies are clamping down on expensive drugs and so on but Wellbutrin came as a generic which is actually cheaper than most SSRIs and other drugs that are not generic yet. Secondly, I know that there is product called Zyban that is basically a rebadged version of Wellbutrin but much more expensive (like as if a doctor couldn't tell the difference) and even if it was used for smoking cessation purposes, wouldn't it behoove the insurance company to promote healthy lifestyles, like smoking cessation and if it can be done effectively (proven in multiple randomized controlled studies) and less expensively by using generic Wellbutrin instead of Zyban, then it would be better for everyone? The line of questioning was galling to say the least. They finally did approve my request after spending nearly 20 minutes on the phone. All I could think of is, "what a waste of my time." And speaking of waste, what are these pharmacy benefit managers doing trying to put a huge barrier between me and my patient? I spent nearly 30 minutes in the patient visit to explain the risks and benefits between all the antidepressants and I have to deal with some pharmacy benefit manager why I'm not prescribing Wellbutrin for smoking cessation purposes? They might as well just tell their patients what they can or cannot take, not taking into account the past medical history, allergic reactions, so on and so forth. Take the doctor out of the equation because we're just wanting to prescribe the most expensive medications because we watch so much of those ads on TV telling you the greatest drug there ever is (except in the small print or fast speaking because there are some side effects. Oh never mind).

I generally don't mind helping patients deal with their insurance companies; but there comes a point where things get so absurd and it will only get more absurd because the doctor-patient relationship is no longer considered sacred and important anymore. I know that there are some questionable doctors out there that might be spoiling it all for everyone else, but the current system (see my diatribes below) feeds to the dysfunction that is occurring everywhere. There is so much evidence (much of it in European and Asian countries) that show the benefit of a good doctor-patient relationship (when it comes to antibiotic use/misuse; malpractice), but nobody here seems to want to foster that relationship here in the US. Again, it's all words, but no action. There has been no significant recent legislation that demonstrates how important it is to address this situation (with maybe the recent announcement that Medicare is revising and increasing the physican fee schedule with the intent that they value doctors spending more time with their paitients).

Also yesterday, I was dealing with a problem with Oregon Medicaid insurance that has been on my backburner for several months, thinking it would go away somehow (but of course, it never does...Murphy's law). There was a patient of mine that has Medicare as his primary insurance but has a thing called a Qualified Medicare Beneficiary (QMB) program that is under the auspicies of the Oregon Medicaid program. It used to be that he was qualified to be on Oregon Medicaid which was not a major problem as I see patients that are on a managed health care plan that receives funding from Oregon Medicaid. The straight Medicaid (or open-card, as they call it here) pays very, very poorly from every standpoint of reimbursement ($20-30 dollars for a 30 minute or equivalent visit) . But if I see someone on the managed care Medicaid, I get paid better (not by much, but better). I don't know why there is a discrepancy. I also don't know why if someone doesn't qualify for Medicaid, why they can be on the QMB program and be treated like a Medicaid patient (in terms of reimbursement) anyways, which I'll explain next.

Anyways, this patient somehow no longer fit the income requirement for Oregon Medicaid. He made too much money. But now they placed him on this Qualified Medicare Beneificiary (QMB) program that is supposed to cover for the copay, co-insurance, and deductibles. What they neglect to tell providers that they ask the providers to subsidize the care of these patients because they (Oregon) don't actually pay the copay, co-insurance, and deductibles. They determine how much you get paid based on the poorly reimbursed Medicaid fee schedule (described above). So let's say that you charged a visit for $100 for Medicare. Medicare only pays 80% so you get $80 and the $20 remaining is the patient's responsibility. But if they have this QMB program, the $20 is supposed to be paid by Medicaid. But not as you would expect. Since the equivalent cost for a $100 Medicaid visit is $40, then they are not obligated to pay more than what you received by Medicare ($80). They claim that since I do see Medicaid and Medicare patients that I have relinquished my ability to balance bill the patient and I have to follow these rules. I know that I have chosen to see the patient but the whole logic of the reimbursement scheme seems quite absurd. So, what they actually claim and what they actually do is two totally different things. What it comes down to is that as the provider, I subsidize their care. Given that it's only one of my patients so far is not such a big deal. But let's say Medicaid continues to lower the income requirements which mean more and more Medicaid patients no longer are on Medicaid (which is actually happening right now) and happen to be on this QMB program, you can see where this is going. All these struggling primary care physicians will be shutting their doors because they can't afford to practice anymore.

I went into medicine because I wanted to help people. I also do make a living being a physician. But one cannot continue to be a physician if their pay is getting diminished by this system of legalized extortion and bribery. It's the old adage, one cannot help others if one cannot help oneself. I look around and see all these different services offered (dentists, optometrists, car service, sewer service) and I am puzzled every day to see that what I get when I provide my services, is less than those services that I just mentioned. I knew that going into medicine and I went into it with my eyes wide open. The state of affairs were already a mess. What I didn't expect to see is how nobody seems to want to do anything about it. Either family physicians are in complete denial (and I do suspect that academic medicine is in some ways about not seeing the problem) or we are too stuck in our old ways that we cannot imagine what it would be like in any other system. The "good ol' days" are gone.

You're probably wondering then, "If I'm so unhappy about the situation, why don't I do anything...like go into the local chapter of the American Medical Association or American Academy of Family Practice, and so on?" Well, I know myself and I have been in situations where there is politics. Being a chief resident several years ago gave me the insight I needed and I know myself better than I had been before I had done it. I realized that I'm not really a political person in that sense. I am very opinionated, but not political. I tend to want to do things and make change rather than just talk about it. So therefore, that is what I am doing...doing my own medical practice the way I want to do it and the way I feel things should be. I also know that I have to accept the negatives that go along with it (running your own business for example, being on your own, feeling isolated and all that good stuff) and knowing that there are the things that are beyond my control (like public policy, legisations, rules, insurance, people). Just like one of the 12 steps for Alcoholics Anonymous, "Accept the things you cannot change, and know the things you can."

My Diatribe

This is a continuation of where my story ends off as mentioned in my website (under "History" and "Practice Stories")

What I had seen, experienced, and read about during my years in college and medical school (in the 1990's) was the decline of the United States health care system over the past several decades. Although there were good intentions by all (physicians, government, health care administrators, insurance companies) to try to "fix" the system, we are now left with a fragmented health care system that does not effectively address the spiraling cost of health care. Symptoms of this ailing system are increasing health care costs and decreased access to care. What I believe are the major problems with this current system stem from four major factors. These are (in no particular order):

1. Over-specialization
2. Lack of focus for preventative care
3. Medical malpractice
4. Over-reliance of pharmaceuticals.
(I suspect at this point in the diatribe, there is going to be a lot of flaming going around).

Overspecialization limits access as patients usually have multiple health issues and no one specialist can address all of them in an effective manner. This is where a primary care physician can provide efficient care. Unfortunately, physician reimbursement schemes in the United States do not provide incentive to support primary care providers. In fact, it is driving down the number of providers, limiting access to care even further. Some of the evidence for this includes a decrease in matched residency positions for the primary care specialties reflected by a decrease in interest by medical students. There is also a decrease in active primary care providers due to burnout. A recent article from the American College of Physicians reported that unless there is a significant change in health care policy, we will see the collapse of primary care as we know it. I believe there there is too much emphasis on specialist care and not enough on holistic care. Don't get me wrong...specialists do play an important role and they must be compensated fairly but there must be some equality and fairness to the reimbursement scheme. If there is any serious effort to fix the decline of primary care, the reimbursement schemes must be adjusted to reflect that. Otherwise, it's all lip service. These schemes are developed and based on rules set up by Medicare (relative value units and such). Only through governmental change can this be trend be reversed. Unfortunately, I also believe that the US government has become inextricably linked to those with the money (special interest groups and lobbyists) that make it difficult for any such change to happen. But that's for another topic...

Lack of focus on prevenative medicine and services continues to be a sore spot. It's all talked about on the news, the medical journals, on TV, but there is nothing that indicates any significant policy change that suggests that we have turned the corner. For instance, it was only just in January, 2005 that Medicare had recently started covering for preventative care services, but even then, it is very limited in scope. However, preventiative services start at the beginning and that means children. The disheartening thing about our current health system is the increasing number of uninsured children. Where I work in the urgent care, I see so many children that could have had preventative services and adequate management of chronic illnesses such as asthma so that they could avoid a major hospital bill. I see frightened families who are unable to afford basic medical care and only until they are near death's door do they go to the hospital in desperation. The cost of desperate care is always more than the cost of prevention. To remedy this, there must be incentives to place a higher value on prevention (or even have coverage) by the payer, whoever it may be.

Medical malpractice is also affecting access to care as physicians are under economic pressure and practice defensive medicine which both increase health care costs. When did this become a crisis? There are some that believe that doctors have become less trustworthy. There are some that believe that the medical malpractice insurance companies are inflating premiums that don't reflect the number of malpractice payments. I think its probably both. There is a perception by patients, and rightly so, that doctors are not as trustworthy and this goes back to the lack of a doctor-patient relationship. We try our best, but given the economic model of our current health care system, doctors are driven to see as many patients as possible in the limited time that we have. How can one possibly establish a meaningful relationship in 5 to 10 minutes? Unfortunately, that appears to be a norm rather than the exception in these times. When there are less primary care doctors available (see above), how can such a system survive? The only result is decreased access to care. Patients aren't able to be seen in a timely manner and when they do, they only spend a scant amount of time with their physician. No wonder patients are skeptical. If that were the case for car mechanics or any other service industry, I'd be fuming! It's no wonder that patients just resort to going to the emergency department because they can't see a doctor. This affects everyone because the costs of the ED visits just gets passed down to the ones who can pay. What that means is that for every uninsured person who receives essentially subsidized care, that subsidy is paid for by the insurance companies who then passes down that responsibility to those who can afford health insurance (businesses or individuals). Which leads us to the concept of increased cost.

The significant influence of the pharmaceutical industry cannot be denied. The amount of money that is poured into advertising as well as direct-to-patient marketing translates into spiraling costs of medications. The temptation by physicians the use the newest drugs further fuels the fire. Besides patient marketing, there is heavy physician marketing which further influences prescribing and treatment practices. There are few things about pharmaceuticals I have observed which I have no particular answers to. There are proponents from the pharmaceutical industry that say that the high cost of new medications come from the research costs. However, there is pretty good evidence that suggests that research only contributes to a smaller percentage of the product's cost and the majority goes into marketing. Big Pharma also states that most of the research, development, and production of the medications come from the United States; but from my own scanning of pharmaceuticals; the majority come from other countries when you read their "Made in" labels (i.e. UK, Canada, Japan, France, amongst the ones I've seen). Seems kinda fishy to me. What's even more of a travesty is that when I cross the border to Canada, there are equivalent medications (i.e. Zyrtec in the US) that are now over the counter and cost nearly 10 times less than the US equivalent ($4 as opposed to $40 for the same quantity!!). So when there are people who say that drugs coming from other countries besides the US do not stand up to the same rigorous testing and quality standards (i.e. the FDA), and therefore are inferior; or it takes more money in the US to develop and create these medications; all of these arguments are so hypocritical...especially when the drugs that are sold in the US (approved by the FDA) are made from these "different" countries. Furthermore, it makes no sense to me that the nonsedating antihistamines need to be so expensive and still need a prescription when the ones that are over the counter (like Benadryl) have serious side effects (sedation) that put patients in danger if they are not careful (driving). Can't help but feel puzzled by that either...

The take home message from all of this is that I think that there should be no "business in medicine". Health care should not be "for profit". That includes medicines, research, health care. To be "non-profit" doesn't mean that those in the health care field should not get paid. It means there there should not be any CEOs making billions of dollars in take-home pay or any participant in the health care delivery system (physicians, insurers, consultants, pharmaceutical companies, medical technologies, electronic medical record vendors or programmers) that think that there is a "killer" profit that will increase their stock options when they do anything health care related. I think that capitalism has run amok in the health care industry because it is so easy to take advantage of people willing to find that magic pill or treatment. The fact is, there should be no temptation in health care delivery because I believe it is unethical to tempt people with a treatment that they cannot necessarily get because they don't have enough money; unfortunately, health care in the US is all about the have and the have-nots. It's a cruel reality. We have a very ill medical delivery system and it's on life support. In subsequent posts, I'll be discussing more about what I've done as a solo family physician to "survive" on this broken system and what got me there in the first place.

Prelude...

This is the first posting of the About Family Health Blog site. This will be the place where I will be accounting my experiences and opinions about life as a solo family physician in Portland, Oregon. To start off, here's the link to my clinic website: http://www.aboutfamilyhealth.com.