Friday, December 14, 2007

Regulating Away Healthcare

It's become a sisyphean nightmare.

Endless reguirements for documentation to get paid, defending one's actions so the patient will get paid, justifying one's actions so the hospital will get paid, while covering your ass so you won't get sued. All while trying to take care of patients.

We are left to wonder, where has healthcare gone?

The answer is simple: it's gone the way of the bureaucrats.

It's gone the way of quality assurance.

It's gone the way of intolerance to error.

It's gone the way of patient satisfaction surveys.

It's gone the way of sterility, MRSA screens, hand sanitizers and no white coats.

It's gone the way of efficiency and cost-effectiveness: to electronic medical records that use voluminous electronic plagiarism to get the maximum Medicare allotment of money for the least possible work while doing nothing to improve the actual management of a patient. (Being a slave to the inpatient world, I don't know how I'd survive without this now).

And now, it's going the way of guidelines on top of guidelines. You see it wasn't enough to have guidelines for management of acute coronary syndrome, or non-Q wave myocardial infarction, or management of heart failure. Now we will soon have guidelines directing us to which coronary stent we should use. Mandated by the very FDA who is paid by the device companies to review their products. The same FDA that will charge $43,190 to review a single direct-to-consumer ad, plus a one-time operating reserve fee of $82,780, because they have to pay 27 additional staff members to assist with those reviews.

Bureaucracy on top of bureaucracy.

All done to feed more bureaucracy, not to really effect healthcare delivery.

It's no wonder the healthcare industry is the second most regulated industry behind the nuclear power industry.

I searched for AHA (American Heart Association) Scientific Statements and found 16,442 such statements on everything from heart attacks in the elderly, to dietary recommendations, heart attack care, arrhythmias, evaluations of athletes, and much more. It is an impressive array of statements and recommendations. But these "statements" and guidelines have become so commonplace, that their usefulness has waned.

Except to lawyers who say, "See, I told you so. Now you have to pay!"

Or regulators who say, "You idiot! I told you not to do that!"

And insurance companies bent on denials: "See, we don't pay for that under those circumstances."

Fortunately, I know plenty of doctors who listen to and speak with their patients. They've stopped seeing people in 7 minutes. They see them in 15-, or 30-, or 60-minute appointments. They don't miss things because they take their time, are thorough and follow-up with the referring physician or family. They work patiently, yet efficiently and never say no to a consult. Even on the same day. And their practices are thriving.

No voice recording on the phone. Real people who respond to your needs.

No bureaucracy.

They're entrepreneurial. Risk takers. Organized.

And they don't take insurance. Ever. But they'll help you get reimbursed, if you so choose.

This is the wave of the future, and slowly, gradually, things will change.

For the better.

Now I just have to figure out what us specialists will have to do to survive...


Image credit.


Bruce said...

Well said, although to read the accounts of William Carlos Williams and Lewis Thomas describing Medicine in the early- and mid-20th Century, doctors were stymied at every turn then, too. Just different battles.

As they relate their experiences, it is clear that the physicians of that era worked very hard. No government or third party payment bureaucracy, but, very often, no reimbursement at all. No guidelines, but no effective treatment for many diseases. No hospital quality assurance, but no infection control. No EMR, but no legible records.

Maybe we've made a little progress in spite of ourselves. Nice post!

Kb said...

A doctor's wife called last night to set up an appointment and gave us a time slot at 5:30 PM I told her that as long as she was okay with him missing dinner that would work. She said, "He is rarely home for dinner, but he loves what he does and that makes all the difference in our lives."
The one thing that I think holds the great doctors up from the good is the way they put patients first. Despite all of the "crap" you still put your patient's best interest first and give excellent care. We appreciate it so very much!

Anonymous said...

Dearest friend of mine is a nephrologist. Dialysis is covered! So your medicade patients reimburse you though the government 80% of your costs. So you are forced to donate 20% of the cost of every medicade patient. Medicare patients (everybody else) are having their reimbursement rates dropped 4% this year, and probably the same every other year into the future. So at some point there simply will be no dialysis except for those that pay cash. How many times can they revisit their practice to try to make money and reduce overhead when the amount taken in is shrinking every year and the costs are increasing every year? This is not a sustainable situation, but they march on to extinction.

I suppose the politicians know that if they bankrupt the docs slowly enough they wont realize what is happening until they are already too poor to hire the good lobbyists.

Anonymous said...

Dr W,

More than 20 years ago, Paul Starr won a Pulitzer Prize for his book, the Social Transformation of American Medicine. Among other things, Starr supposed that medicine for better or worse was in a process of industrializing. The cottage-industry, solo practice was disappearing. Multi-specialty groups were the future and with them, the methodology of practicing medicine was going to change fundamentally to what he called an industrial model with all the attendant attention to process definition, improvement, review, and discipline.

I was doubtful - even skeptical - but I think events are proving him correct. (Perhaps doctors in the 80's already knew this was happening and Starr is getting too much credit for the insight.)

Now new questions must be answered: can doctors' roles continue to be focused on care giving? Must doctors become integral to the management of the health care "industry"?

A class of professional health care administrators is forming. The list of positions at NCQA is but one example. It worries me that there are not nearly enough doctors in this class. It also worries me to think of trained clinicians spending significant time in health care management rather than patient care. What to do? Doing nothing is not "nothing" - it's a decision.

I believe there is a vacuum in patient-centered health care management and that doctors, by their inaction, are permitting this to happen. I believe doctors have no real choice other than to become directly involved in the management of modern, "industrialized" health care.

It does no good to observe, and lament, the empty bag. There is no longer a cat in it, and it won't go back in.

Unfortunately, as the hackneyed saying goes, doctors face 3 choices to lead, follow, or get out of the way. Two of those choices spell disaster for American health care.

Which brings me to my next worry - does there remain sufficient incentive for top people to enter the field of medicine, seeing the challenges within it?

Sorry to be so long winded. I would have come to a point if I had an inkling of a solution.

DrWes said...


Your insights eloquently demonstrate the conundrum we physicians experience these days. Financially, the industrialization of medicine has morphed medicine into a "production line" mentality - get more patients through in less time - and the continued declining fee-for-service model has further catalyzed this transformation in hopes that revenue cuts can be postponed.

Perhaps I am idealistic, but I sense a shift from industrialization to personalization of medicine. Patients are better empowered through the vastly-improved availability of information technology to take the reins of their own healthcare again. The doctor-patient relationship is slowly gaining respect again - in part because people are demanding it. Never before has there been such exposure of the waste, fraud, abuse and bureaucracy that is our system today. And more and more, hospitals and third party providers are having to adapt to the demands of the patient and doctor. After all, if the hospitals and policy wonks continue to scapegoat the doctors as the root of all evils to the costs of healthcare, as you say, there won't be too many left to deliver the care.

While doctors can (and should) lead the charge for healthcare reform, presently we do not hold the money - the third-party players do. At least so they think.

In reality though, it is the patients who really hold the money initially, but most don't realize it. They willingly enroll with their employer's "health benefits" with an automatic deduction from their paycheck, feeding the beast of third party care.

When patients have had enough covert rationing through claims denials, exorbitant bills that exceed their life-time allotment for healthcare and the like while the financial institutions like insurers (yes, Virginia, they are FINANCIAL institutions bent on profits, NOT healthcare providers) and these realizations circulate to the common man (via the internet and other media), then change will occur. Call it "grass roots."

But as you have pointed out, human nature is to take the easy path - don't drive the bus, instead, let it be driven for you. "It's too complicated," many will say.

Unfortunately, health care looms as an ever-growing cost to all of us, and we'd better start moving toward the front of the bus to grab the wheel before we're all run over by bureaucrats more interested in the system than the patient.