Frustrations in Providing Good Patient Care:

During a moment of exasperation while desperately searching for a "covered" medication or service on the computer in the exam room with a patient, I have been known to mutter, "I sometimes wish I were practicing in Borneo."  Or something like that.  What I mean by that is that I wish I didn't have so many restrictions to just doing my job.  My job is taking care of patients.  My job is to provide the best service in the safest way to help my patients improve or maintain their health. 

I may know exactly what medication the patient would do best on for a given problem.  However, when I have to dodge around insurance restrictions, cost issues, availability problems, and other restrictions, I may have to "settle" for something decidedly less appropriate.  Blame Big Pharma (for the high price of medications), or blame health insurance companies and their sometimes very odd restrictive formularies (approved medication lists).  Each would have their excuses:  Big Pharma: "We need to pay for all the years of research and development of our drug, because it will only be a protected Name Brand drug for a few years before it goes off patent."  Health insurance companies: "We need to keep costs down to keep premiums down."  Anyway, this is just one example of the restrictions to practice that physicians face. 

An even more staggering problem is the unfortunate patient on Medicaid (the state funded health insurance for persons of low income).  Medicaid drug formularies are the most restrictive of all.  Many specialist physicians won't see patients on Medicaid, so if I want to send a patient with Medicaid to a dermatologist, for example, I have to have my staff search high and low to find a specialist (hopefully within 150 miles) who will agree to see them.  Medicaid patients have to wait months on a long waiting list if they need specialized services of a psychiatrist. 

All I want to do is to help get my patients healthy and keep them that way.  Without jumping through numerous "hoops."  Probably 50-60% of my work effort is spent making my way through these mazes of restrictions and roadblocks to good patient care.  All of us as physicians accept this as reality, and it is the favorite point of contention during our "gripe and moan" sessions in meetings. 

Modern physicians I think feel as though they are the most important link between the patient and good health care, but they are being rolled over roughshod by a medico-legal-insurance system that is completely out of control and that ignores the wants and needs of the patient as well as the physician. 

The problem is, we are generally really good at what we do--taking care of patients--but we are NOT good at changing the system.  We don't have time enough in our work day to even think about trying to change the system. Throughout my four years in medical school, I never got ANY instruction in how to work with insurance, how to do coding and billing, or really any business instruction. 

A new emerging model of practice is what has been called "boutique medicine" or "concierge care."  In these models, a few physicians will get together and assemble a collection of several hundred patients.  Each patient in the group pays an annual fee to have the group of MDs be their team of personal physicians.  The annual fee is designed to cover the very dedicated services of the physicians, and in return the physicians are virtually "personal physicians" of the members.  The patients can meet with their physician during a long office visit (which can be billed to the member's insurance), but much of the interaction with the physician is on-line or by phone.  Each physician may have around 200 individual patients they are "assigned to," and if each patient pays $2000 a year to maintain that service, then the physician makes $400,000 for the year.  Office visits and hospital stays and lab and imaging are billed to existing insurance.  But the patient's physician is THEIR physician and sticks by them through thick and thin, during hospitalizations, basically for everything. Of course only relatively wealthy patients would be able to choose this option, as they would have to pay the annual fee AND insurance premiums. 

There are some variations on this model of "concierge care," but many overworked physicians hear about these models and say, "Gee, where can I sign up for that?"  Some newer models have employers hiring groups of physicians in a somewhat similar manner, and pay the physicians for their services--completely avoiding involving health care insurance.  They place the emphasis on wellness and preventive care, and reward physicians more for keeping the patients healthy. 

So there is some evolutionary movement to try to take insurance out of the loop between patient and physician.  It will be interesting to see how far this actually goes. 

It is a well-known fact that other countries in the world spend far less on health care and have much healthier populations that we in the United States.  This is a huge issue of embarassment to the U.S.  I have a few opinions on why this is so: 

--We have a tremendous bureaucracy tied up in health care:  Medicare, insurance companies, and some of the largest pharmaceutical manufacturing companies.  This, in my mind, tremendously reduces efficiencies and poses an incredible amount of mass--thus inertia--in trying change things toward more efficiency.

--We have an extremely diverse patient population as opposed to the northern European countries who have the best health-to-expenditure ratio.  Diverse in terms of income, race, culture, and belief systems.  Therefore we can't practice "one-size-fits-all" medicine.  Reducing efficiency. 

--We are an incredibly litigious society.  I don't care what anyone says, I know that the threat of being sued enters into my medical decision making all the time.  And, knock on wood, I've never been sued!

To be continued......