Halloween HorrorsPaul GrossOne October evening last year, I went to our local pharmacy to pick up a prescription for my daughter. I made sure to bring Cara's insurance card because my employer had switched us to a new health plan.I wasn't sorry about the change. Our prior plan had been operated by incompetents--although they might only have been crooks, I couldn't be sure--who also managed our flexible spending accounts. These accounts, you may recall, collect pre-tax income from your pay and then return it to you to pay for out-of-pocket medical expenses.With that plan, nothing ever worked as advertised. I would submit a dental bill for reimbursement and the company would review it for three months before sending me a denial notice, stating that my health plan had no dental coverage."I know that I have no dental coverage," I'd tell the representative on the phone. "That's why I put a big X in the box labeled Flexible Spending Account.""You sure did!" she'd say cheerfully. "I don't know why they did that. You'll have to submit it again. This time, put my name on it...."Or I'd submit a claim for a medical expense that was covered, then hear nothing for months and months."We've fallen behind," a weary-sounding representative would lament. I could picture the ceiling-high stacks of claim forms swaying on her desk. "You should be hearing shortly..."No one ever said "I'm sorry." No one ever acknowledged the annoyance of the paperwork or the aggravation of waiting on hold for a representative. No one ever said, "Gee whiz! We hoped you wouldn't notice, because if you forget to contact us, we get to keep your money," although I suspected that this was one of their operating strategies.So I was happy with the change in health plans. And there at the pharmacy, I optimistically produced my daughter's new plastic card.The pharmacist punched something into a computer and stared impassively at a screen. After several minutes, I wandered off to look at vitamin capsules and cold remedies.When I returned ten minutes later, the pharmacist was on the phone with my insurance company. Ten minutes after that, he was on hold for a different company, the one that manages the pharmacy plan.While the pharmacist waited, I browsed the magazine rack. Then I made my way to the Halloween aisle, where I saw candy similar to the trick-or-treat leftovers desiccating in our freezer since the previous October.The pharmacist finally beckoned and rendered a verdict: "Your daughter isn't covered under your pharmacy plan.""What?""They've got you on their system, but no one else in your family.""I can't believe...""They say you've got to talk to your benefits representative."I thanked him for his thirty minutes of trouble. The next day I called my benefits representative, who reassured me that our entire family was in their system. Days later, my wife tried to fill a prescription--no luck.The following pattern repeated itself over the next few weeks: (1) I'd call my benefits representative and receive assurances that the problem had been fixed; (2) we'd try to fill a prescription for my wife or daughter; and (3) the pharmacist would tell us that she wasn't in the system. Finally, weeks later, somebody somewhere flicked a switch and--voila--the pharmacy plan kicked into place.Which brings me to the upcoming presidential election.One of the candidates for our highest office is advocating new deregulations that would encourage Americans to comparison shop for health plans in all fifty states. This is nifty, if your idea of a simpler, more efficient health system is more health plans.My first reaction was: who has time to spend evenings and weekends comparison shopping for health plans in all fifty states? And who wants to repeat the shopping trip in a year, when a plan's sticker price is sure to go up? Each change in plans, of course, means new cards, new forms, a new list of covered doctors....The last medical comparison shopping I did was to hunt online for a Medicare Part D prescription drug plan for my 83-year-old mother. It was a nuisance. Years later, she's still using the same plan. Not because it's still the best for her--who knows?--but because it's just simpler that way.The suggestion that some nimble shopping in a health-plan emporium is going to fix our health-care system would never occur to anyone who's wrangled with prior authorizations, changing doctors when one plan flips to another, or getting inappropriate bills because last year's insurance company was incorrectly charged for this year's blood tests.Most people understand that each new plan--even a better plan--is a new bureaucracy. One more snarl in a tangled health-care web that already boasts hundreds of commercial health carriers and thousands upon thousands of different plans.The only person I can imagine embracing a
One thing I love deeply about being a family doctor is that I get to take care of people--body and soul. A patient comes into my exam room with a litany of physical symptoms ("My shoulder...my knee...my stomach...so tired...this nausea...") and then, in response to a questioning look, suddenly bursts into tears.
It's all mine to deal with. The shoulder. The stomach. The tears. I get to gather the pieces and see if we can't put this broken person back together again.
What a privilege.
And yet the joy of primary care is also its curse. With each patient, I have to keep track of everything--the trivial and life-threatening, the physical and mental, the acute, the chronic and the preventive. And try as I might, I simply don't have enough time.
On paper, my office schedule looks simple: I see one patient every fifteen minutes beginning at 8:30 a.m. If I stick to my timetable, I can wrap up my twelfth patient by 11:30, finish up any leftover paperwork and enjoy an hour's lunch before starting again at 1:00.
The reality is that I'm never done by 11:30. In fact, my colleagues and I are often still seeing our morning patients at 1:00, when our afternoon session is supposed to begin.
Lunch hour? Wouldn't it be nice.
And I have it easy. One hears of offices scheduling patients every ten minutes--every ten minutes!--and doctors "seeing" fifty patients a day.
Doctors talk of running on a hamster wheel. Patients complain that their doctors seem distracted, don't take the time to listen, and run late--as I routinely do.
Am I a bad doctor--disorganized and inefficient?
Or maybe I'm doomed to fall short as I bump up against powerful economic forces--the "do-more-with-less" pressures that make medical administrators everywhere create schedules like mine, designed to bring in enough money to keep health centers afloat but which end up hustling me and my patients along at an impossible pace.
As a nation, we are now trying to fix our foundering healthcare system. Before we set new rules in place, shouldn't we first ask this basic question: how much time is actually required to see a patient?
Looking for an answer, I decide to record the events and actions of a recent office visit.
Today I'm seeing Minerva Santos, an extremely nice 49-year-old woman with diabetes and hypertension. Mrs. Santos is a great patient--she takes her medicines, shows up for appointments and is agreeable and uncomplaining. Compared with many other patients who are frail, in chronic pain, depressed, argumentative or uninsured, she's easy to care for.
So how long should a visit with Mrs. Santos take? Let's see.
At 8:30 this morning she walks in, placid and neatly attired, with short reddish-brown hair.
After a smile and a handshake, I tell Mrs. Santos that I'd like to review her labs and check her blood pressure. "Is there anything you'd like to talk about?" I ask.
"I've got a cough that's really bothering me," she says.
"Tell me about that." I add cough to my internal agenda. She describes a recent upper respiratory infection that flared briefly into a fever and now has her sniffling and hacking.
"Why don't I take a look in a minute?" I say.
"And I need all my prescriptions renewed," she adds. Prescriptions, I echo to myself.
We peer together at the computer screen. Mrs. Santos's measure of long-term diabetes control--her HbA1c--is elevated at 8.4. "We'd like to see it below 7," I tell her, "to reduce the risk of complications from your diabetes." Meanwhile, I'm wondering why her control isn't perfect.
Mrs. Santos checks her blood sugars at home; she tells me that her evening sugars are above 200 (normal is 100). Asked how she takes her diabetes medications, she says, "After eating, just like my last doctor told me to." This is odd, as they're supposed to be taken before or with meals.
We move to the examining table. I double-check her blood pressure: it's 160/100. Our goal is 130/80. Her throat, neck and lungs are unremarkable. "Looks like a bad cold," I say. "Would you like some cough medicine?""Fine," she says.
She fumbles in her bag and removes seven pill bottles, a modest number for someone with her ailments. I line them up, unscrew the tops and point to the diabetes pills. Could she take them with dinner rather than afterwards? And how would she feel about increasing one medication's dose?
"Okay," she says.
I share my concern about her blood pressure. "It looks like you really do need a fourth blood pressure medication. How about if I give you a new one? You'll take it once a day--with your other blood pressure pills."
GREEN MEDICINE“Does it hurt when you do that? Then, don’t do that!” Groucho Marx“It’s up to me.” Marcus AureliusReality is catching up with us. No matter which side of the aisle one is on, all must agree that while we have the most remarkable system of medical intervention the world has known, the way we consume and pay for it is badly broken. Patients and employers pay more and more, providers receive less and less, where is it all going?A sustainable system of health care will most definitely involve less utilization (rationing, if you must) in some way. Progressive declines in reimbursement have squeezed inefficiencies out, and the expansion of high tech may have leveled off for the time being. Less utilization need not be feared, however, as the case can be made that much of spending on health is ultimately discretionary. It is certainly so with elective surgery, probably with most helicopter rides, often when selecting between medication regimens, arguably with use of chemo / surgery for advanced cancer, and potentially in the very aged and/or preterminal patient who has never had an open, honest discussion with family or trusted physician about their wishes in such a time, to cite but a few examples. But who should have the discretion? The patient can exercise control, as in the stoic Emperor Aurelius, but this is highly unlikely, unless the Groucho Marx School of Medicine picks up steam. Government can take control, which many believe is their ultimate goal. (Interestingly, a reduction in spending is a stated government priority, but then why are they budgeting so much more money?) While it seems tempting to give in to a single payor system, which can happen out of fatigue, frustration, or ignorance, I believe this would doom us all to a far worse fate. The government assuming any more control of the perverse system we have will only pervert it further. We as physicians can control utilization, but as we look at any given patient our thoughts can be corrupted by regulations, fear of liability, need for income, and the fact that there is simply not enough time left in the pace of our current practices to know our patients well enough. If we could spend less on everybody, there would be more room to serve those truly in need of the modern marvels we have developed.To quote yet another long ago celebrity: We have met the enemy, and he is us. We are being driven to look at every patient as needing every answer, no matter the cost, or worse yet as “revenue streams”. If physicians could afford to slow down, and pursue reasonable care, one on one with their patients, then other interests would not have the opportunity to come after us. We may be like the farmers who at first saw tremendous gains in productivity with fertilization and chemical manipulation of their crops and livestock, which led to eventual decline in price per unit. They are now struggling to keep overworked farms both productive and profitable. Medicine may have gone too far. Like them, we might be better off returning to a more “organic” method, and rely on the laws of nature as they pertain to us – pursue effective, common means of management, recognize our limitations, and exercise sound control of diagnosis and treatment, with nothing in mind besides the patient.
This is an Op-Ed I ran in the local paper last month - some of it is specific to local occurrence, but I think it's message is universal. HEALTH CARE: RELATIONSHIPS MATTERIn the debate on health care, there is no shortage of opinion, with widely varied explanations of causes and solutions. One fact that is not disputed is that the provision of health care has become a significant portion of the economy, so significant in fact that it can represent the largest single economic sector in a community. Youngstown is such a place, where the hospitals represent the largest employers in our area. Agreement also is found in the importance of the relationship between patients and their physician, which if respected and encouraged generates an environment of health and wellbeing. Continuity of care minimizes chance of miscommunication, enhances patient compliance, and results in greater understanding on the parts of both patient and provider, all of which correlate with optimal outcomes and improved patient safety. Unfortunately, our system of health care delivery, as it has evolved, threatens both of these important factors. Cost and efficiency are emphasized over quality, exemplified by increased reliance on “physician extenders” (e.g. “assistants” or “practitioners”), or worst yet, “telemedicine”, wherein patients are not even given the opportunity for a real encounter with the supposed professional who is taking responsibility for their life or limb. This is due in part to the idea that health care, especially procedure-oriented care, is increasingly seen as a commodity, which is a dangerous perception, since results of procedures actually correlate best with the amount of time the patient spends in contact with the surgeon before surgery occurs, for instance.While it has been suggested that the use of the Electronic Medical Record (EMR) may obviate some concerns, this premise is theoretical – physicians who are using EMR do not find it safer or more efficient. EMR has never been shown to improve outcomes or safety, and will not replace the essential importance of a real relationship between a patient in need and a physician interested in helping them.The difficult economic climate may be a further threat to our local system of care, for both obvious and not-so-obvious reasons. Financial difficulties can be even more pronounced for the largest businesses and institutions than they are at these times for smaller more local concerns, who may not have committed to grandiose expansion schemes and massive overhead. This is seen in major changes at seemingly immune monoliths like Harvard, who for the first time in generations is making budget cuts, and like the Cleveland Clinic, who is sending out “assistants” with video cameras to outlying areas such as Wooster and Youngstown in an effort to capture more revenue to feed their gargantuan appetite. This intrusion by and for a profit generating entity stands in contrast to, and in conflict with, our local community hospitals and physicians whose mission is to provide comprehensive care to the people of the community where we live, which care is provided without regard to whether payment will be received, again in contrast to what is expected by the Clinic.Health care that is provided in the context of a relationship between a patient and physician is unquestionably the ideal we should pursue – it is as a rule safer and more effective, and is furthermore an asset to the local economy. Changes in the delivery of such care threaten the foundations of quality, safety, and access to care, and should be avoided except in the most extreme or unusual of circumstances. These fundamentals are vitally important as we consider our health care on all levels – national, local, and personal.Thomas S. Boniface, MDAssociate Professor of Clinical Orthopaedics, NEOUCOMFellow, Institute for Professionalism Inquiry, SUMMA, Akron
One More Child Left BehindBrian T. MaurerMaking the diagnosis might be straightforward, but sometimes getting adequate medical care poses a more formidable challenge.It was the end of an exhausting afternoon in our busy pediatric practice in Enfield, Connecticut. I had just finished seeing what I thought was the last patient of the day, only to find yet another chart resting in the wall rack, a silent signal that one more patient waited behind an adjacent closed door.His name was Aaron. Six years old, he sat on the exam table cradling his left arm in his lap. The most striking thing about the arm was the large bluish bulge on the side of his elbow. His mother stood by his side; his grandmother sat in the corner chair."What happened?" I asked."Another kid pushed him off a table at school. He won't move his arm."I took a step closer. "Let's have a look."Gently, I palpated the borders of the blue bulge. Aaron winced in pain. I felt his wrist to check the circulation to his hand. "Squeeze my fingers," I said. He tried and winced again."It's likely broken," I explained. "At this hour all the x-ray facilities in town are closed. Your best bet is to take him to the emergency room," I said, wrapping Aaron's arm in a sling."When you get to the hospital, they'll take a special picture of your arm," I told him. "Give them a big grin so it comes out well, okay?"Aaron's grandmother flashed a faint smile as they walked out.The next morning Aaron's mother phoned the office to tell me that, although the x-ray showed a fracture of the elbow, no "bone doctor" had come to the hospital to treat the break. Instead, she was given the names of some local orthopedic surgeons, with instructions to arrange an appointment with one of them that morning. But none of the surgeons would give her an appointment, so she wanted advice about what to do.When I flipped through Aaron's chart, I saw why none of the local orthopedists would see him. It was all too clear: Aaron's health insurance coverage was through an underfunded state-sponsored Medicaid plan.I telephoned the client services department of Aaron's health plan. A cordial representative proceeded to give me the names of several participating orthopedic doctors in the area."Hold on," I interrupted her when I heard the first name. "The mother already called that practice and was told they were no longer participating.""Sometimes that happens," the representative told me. "The doctor opts out, but doesn't inform us directly, so we still have the name on our list." She gave me three other names and telephone numbers. "Call me if you're still having a problem," she said cheerfully. "Have a nice day."Feeling frustrated and irritable, I delegated the task of locating a participating provider to Laura, one of our medical assistants. "When you find someone, schedule the appointment and call the mother to let her know," I told her, then turned my attention to my morning patients.I returned from lunch to find Laura still on the phone. "None of the practices you gave me would accept this kid's insurance," she said. "I called client services again and got six more names. Each office was happy to schedule an appointment until I told them the insurance carrier. I can't believe that no one will see a six-year-old boy with a broken arm!""We'll demand an out-of-network pre-authorization for care and send him to Children's Hospital in Hartford," I said, gritting my teeth. "I'd rather he be seen by a pediatric orthopedic specialist anyway." And I knew that Children's Hospital was just a half-hour drive away.Somehow Laura got the pre-authorization approved and called Children's. I heard the phone slam down, then her footsteps resounded in the hallway."This is absolutely crazy!" she cried. "They won't see him, even with a pre-authorization! Now what?"I rubbed my forehead as though it were Aladdin's lamp. At this point I needed a magic genie. I was running out of options."Why not try the orthopedic clinic at University Hospital?" our office manager suggested. I knew that only adult orthopedic surgeons worked there--and that it was further away."It's a long shot, but--call them," I said, conscious of the tightness in my neck.A few minutes later, Laura shouted, "University Hospital will see him!" She was ecstatic. "They take his insurance!"My jaw dropped. "Wow. Great! So now all we have to do is tell this mother she has to drive an hour to have her child attended by a participating doctor."I glanced at the clock. All told, we had placed eighteen phone calls over four hours to get one child the care he needed. When he was finally attended at University Hospital, twenty-four hours had elapsed since the time of his injury.When this incident occurred, in 2003, 43 million Americans had no health insurance. Since then, the nu
An all too common situation these days - and perhaps a harbinger of things to come when "everyone has insurance", since the only insurance government can offer will essentially be what this child has.(I wonder though if the writer will heretofore not refer "paying customers" to those docs who refuse to see the child?)Back in my training, and to this day in my practice, we recognized that we were paid well for most of what we did, so when it came time to do it on occasion for free, we did (and still do). Then the usual was 165% medicare, now that it's 102% - if that - many find it harder to be generous. This seems based on a sense of entitlement that physicians have developed from those once upon a time days when unit prices were higher. Nowadays they run the mill and turn out more units at lower prices to maintain the bottom line, and just can't seem to afford the occasional freebie. It was also easier when everyone gave the same degree, which meant that no one doc or practice was burdened.There is a well done piece in today's Wall Street Journal by Dr. Flier, the dean of Harvard Medical, not normally a place I look to for ideas, that summarizes the issue and the ultimately inadequate response by all public figures - gov't, insurers, physician orgs a la AMA - in the matter. Doesn't look good in the long run.... I don't believe we can fight city hall, as the saying goes. They will pass whatever is in their interest. I do believe we can continue to care for our patients and if we do so with a conscience, and with a purpose beyond income, and with a generosity toward others, then the matter of who is paying and how much will be of no consequence. We should behave better than that, rise above the petty issues of the day, and regain the role of the true professionals we are supposed to be. Up there they can't get to us -TSB
For stories about different aspects of the medical system including the endings of the three incomplete stories I posted here, check the website, Pulse: Voices from the Heart of Medicine. Paul Gross, the publisher, has given me permission to link to his website: www.pulsemagazine.org. Look in 'archives'.
Change Happens It’s hard not to be cynical in days like these. While some recent events such as the massive economic collapse were difficult to predict, the progress of the attempted “reform” of healthcare by our lopsided federal government has been more predictable. The only positive I see so far is that the self serving avarice of virtually every member of the legislature has been exposed for all to see. It will be very interesting to see where it goes from here. Will the electorate express itself and clean the House (and Senate), or will its collective anger succumb to the ennui of the relative well being left over after decades of affluence? How will the legions of those of us soon to be even more beholden to the federal behemoth respond to the new shackles that will doubtless be applied?I read an editorial recently that likened our current situation to that of the Colonists under British rule. It analyzed present events and found correlates with those during the time of the Revolution. The conclusion however was curious – we should work with our organizations, write letters, and phone our representatives, even the President himself. If my understanding of history serves, when pressed beyond their limits of tolerance, the Colonists didn’t lobby their Lords, call the King, or petition the Parliament – they threw the tea into the harbor. They put everything they had at risk for the sake of their freedom, and for the sake of their faith in who they were and why they were here.Who are we, and why are we here? Too much of our response to reform has been ultimately about preservation of the status quo, which while understandable is not tenable. The system in which we work has been perverted, taken over by the insurers in search of profit, and the government in search of power. Along the way, physicians have been led away from their focus on the patient, distracted by the pressures of liability and regulation, and sometimes allured by the desire for revenue.I don’t know what our metaphorical tea may be, or into which harbor we may need to throw it, but we had better start thinking it over. The government will do what it will, the insurers will still profit, and the patients ultimately will stay ignorant of what they need and how to get it. It will remain our obligation as physicians to represent the patients’ interests, ahead of the GDP, ahead of the government, and even ahead of our own needs. If we cannot do this, there will be nothing left for which to fight. If we can, however, we will preserve the real health of our patients, and the integrity of our profession.
I've been an orthopedic "trench doctor" in the SF bay since 1988. I've reached the point where I can't bear to stand by and watch the rapid decline of the nation's health. I'm now mid-way through a 1 year sabbatical to participate in healthcare reform. It's rare to find a group of specialists, let alone orthopedic colleagues, with a similar agenda.
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