Let’s examine the origins of the problem in the ongoing debate of the repeal of Obamacare and new proposals.
Care vs Coverage
There is a distinction between access to healthcare and access to health coverage. Patients and doctors are always referring to the former but hospitals, networks, and politicians typically refer to the latter. Needy patients rarely turn away from a physician who can provide a service but many are denied coverage for a prescribed procedure or medical treatment. This subtle but important distinction has led to a significant gap in communication.
Adding layers of frustration are doctors either employed or enabled by the networks that become the voices that direct public policy through a business lens. The rule makers have a completely different perspective than those in the trenches. The patient has morphed into a “customer,” and the physician a mere “provider” of service and the system doesn’t differentiate the value of primary and specialty care.
In hospitals, administrators and support staff outnumber the staffers responsible for the actual day-to-day care. Sadly, incentives in our current system reward hospitals with generous budgets but force others to divert their limited resources away from patient care toward tracking arbitrary quality measures. The patient has becomes less important in this equation; what you do to make a patient better becomes less significant than how you do it—irrespective of outcome. Adherence to a strict business model has allowed medicine, a service industry, to be mistaken for a product.
Due to these pressures, doctors retreated into their offices or now work for hospitals.
Primary cares abandoned their sickest patients to the care of hospitalists. Specialists, supported by innovations in biotechnology, began to shift care away from inpatient settings. Formerly complex operations (like cancer therapy) with week-long hospitalizations became outpatient procedures with low morbidity and low cost. Despite this move to outpatient care, specialists continued to provide coverage for anyone coming to the emergency room regardless of compensation.
The Wall Between Patient and Doctor is Set
With a ground shift, insurance companies began transferring costs to the patient and physician. No one realized someone stopped paying the bill, and many didn’t initially notice their high deductible plans. The response was to replace nurses with business managers to ensure every patient had the appropriate paperwork or be denied access. Our front end began to resemble a TSA security checkpoint. A wall of bureaucracy and regulation tied to financial compensation separated the patient and doctor.
This created a hostile environment, not conducive to good patient care or outcomes. Electronic records are rife with errors because they only approximate a patient history rather than relying on the former natural narrative between physician and patient. But human physiology is still the same regardless of IT requirements; our response to pain, illness, and the desire for the well-being for loved ones is universal. It’s no wonder neither the patient nor physician is satisfied with the healthcare system.
“Just take good care of the patient, all else will follow,” counseled my wise, talented, thoracic surgeon father. But now with little control, it is harder to do the right thing. Fears of financial insolvency force doctors and patients to seek refuge behind the shield of insurance, but with affordable and transparent costs the relationship could be restored. Physicians must have the freedom to take good care of the patient per our training. It’s not that difficult.
Let’s stop squandering precious health care dollars by limiting insurance administrative and marketing costs, rein in ballooning Medicare costs post ACA, and examine the dollars diverted from patients to support the newly created Medicaid bureaucracy. Private insurance companies need to be accountable for premium increases since private enterprise optimizes their margins at the expense of those providing the care.
Independent practices accepting Medicaid and Medicare patients shouldn’t be denied payments to cover expenses; even the Mayo Clinic stopped contracting with Medicare. More doctors are dropping or limiting coverage for the very group the ACA was meant to protect.
Other physicians drop out altogether in the face of diminishing satisfaction and increased stress despite all those years of commitment and training. But the saddest measure of talent loss is in the countless patients needed to train a single, experienced surgeon.
Fixing a Broken System
- Restore the patient to care equation without outside competing interests.
- Remove all incentives, don’t bonus people or systems for just doing their job, pay for services in a fair and transparent way, and scale back regulations to provide a much-needed economic stimulus.
- Respect society’s standards of care; remove guidelines that are misinterpreted as policy and cause negative patient outcomes.
- Remember to follow a prescribed flight plan; when we train to land the plane in the Hudson we need the latitude to do so without interference or fear of retribution.
- Finally, let the patient choose, and let the doctor work only for the patient’s best interests, not the system’s. That is the difference between medicine and public health.
Let’s put medicine back on track.
Dr. Paula Muto is the founder of UBERDOC, a patient to specialist (P2S) direct access web app.