OPINION -- The healthcare system is failing patients and physicians. In a recent article, a 46 year old woman initially presented with shoulder pain, and according to her lawyer, eventually had a heart attack, possibly requiring a future heart transplant. This article isn’t about the merit of this particular lawsuit or tort reform in general. I am an internal medicine physician and see the larger issue of a system failure, and such examples are inevitable. Physicians are set up to fail with resulting patient harm. The reason for this article is to delineate the basic flaws. Understanding how they interrelate answers the questions of how and why the system is failing.
Quality care demands continuity of care, but continuity is too frequently broken. The patient mentioned above presented with typical symptoms for a common, benign condition, yet that incident was the needle in the haystack. She then saw multiple providers.
Current documentation is more about data entry for the purposes of research, avoidance of malpractice and billing than for the purported goal of documenting care, compounding the negative effects of the lack of continuity of care. Each provider no doubt tediously entered a note into an electronic health record. Should physicians concentrate on the patient or clicking boxes? One can’t be done without compromising the other. Electronic records sound great, but they are a distraction, producing generic, template driven notes for subsequent providers to use. The patient is reduced to a pattern of checkboxes and nonsensical pull down statements. The patient’s meaningful narrative is lost. This improves billing, but is terrible for documenting clinical analysis.
Clinical analysis shows how the differential diagnosis was evaluated. Without documenting it, it is impossible for subsequent providers to double check and possibly catch what the previous provider missed. The differential diagnosis forms the backbone of the clinical evaluation process. It is how we consider the things we don’t want to miss, like heart attacks, cancer, etc. Paradoxically, documenting the differential diagnosis increases our malpractice risk and insurance companies misconstrue the “possible diagnoses” as if they were diagnosed conditions. Thus, the clinical analysis has to be left out of the note.
Primary care physicians simply aren’t given enough time. Medicare reimburses well enough for 5-7 minutes of face to face time, which is asinine considering how complicated patients are.
Insurance carriers are incapable of defining and measuring quality. Their attempts to do so degrade the care physicians are able to provide. They claim to be holding costs down and physicians accountable. The fact that the United States spends $2.9 trillion, more than the next nine most expensive countries combined, accounting for 17.4 percent of the GDP, with mediocre overall outcomes, doesn’t corroborate those claims.
An insurance company has never improved the care that I or any other physician has provided. They frequently negatively alter the care we give. The truth is, insurance company contracts are not negotiated, are one-sided and give the insurance company the leverage to influence patient care without patient awareness under the pretense of “negotiated prices” with the provider. This is clearly unethical, but politically condoned. The phrase “preferred provider” is simply a euphemism for “captured provider.” Yes they really use the word “captured,” connoting we are game animals.
Technology, while certainly having positive effects, is not the answer to our basic problems and is being overutilized to compensate for lack of time, malpractice risk mitigation and improved patient satisfaction. Overutilization reduces quality by increasing harms and costs.
Lawsuits while failing to redress any of the above, squelches learning from and making apologizes when mistakes are made, and innovation too risky. The threat of lawsuits promotes defensive medicine, a prime motivation for overutilization.
Physicians know how the system should work, but inexplicably fail to communicate how it dysfunctions. To the extent we fail to communicate our inside knowledge, we are complicit in its failing.
Henderson, DO, an internal medicine physician, now works outside of the medical field.
Comments
Agreement
Thank you for your reply. My
Thank you for your reply. My article is broad in scope so as to hopefully put examples such as yours into some sort of context. It is important to see that there are multiple sides to every issue, argument or perspective.
To play the devil's advocate, there has to be some cost control in medicine. There is no shortage of things on which money could be spent and insurance companies do have a finite supply, as already described in a report here on The Lund Report. All but Blue Cross have lost significant amounts of money in 2015. All "stakeholders" are trying to get a piece of the pie the insurance companies have pooled together. The money the insurance companies have comes from either an employer or an individual with or without subsidies/tax support, who are all nearly maxed out. So it is reasonable that insurance companies try to manage or limit pharmaceutical costs. The pharmaceutical companies continually raise prices for no other reason than to increase profit. They state it is expensive to bring a drug to market, which is true, but not the whole truth. There is an article that could be written on that. Finally, based on personal experience and there is some research supporting this, patients seem to percieve that more expensive medications are better medications.
But insurance companies manipulate what they will and won't cover based on business policy - negotiate lower drug prices. There are medications I would prescribe in the past, that were generic, cheap, effective and had been around for decades. Then one insurance company inexplicably would not "cover" the medication. The best explanation I am aware of is that there are deals made between the insurance carrier and a pharmaceutical company or benefit manager, or so something to that effect, to get better deals on the medication. So the patient and physician are put in a very difficult situation, having to switch from a medication that works, to some other abritary medication due to a backroom deal. It is the backroom deal that is influencing coverage, instead of what is medically rational. I hear the stories of patients who are on medications for years, which was the only one working to keep their condition manageable and then have to jump through a bunch of hoops to get back where they were before.
This of course puts no significant burden on the insurance company as the patient has to change medications, make more appointments, perhaps undergo more testing, lose control of the condition and then get back to the medication they had been happily taking previously. No benefit at all for the patient or the physician - just a lot of aggravation. In the big picture, what happened? More cost and less effective care.
There are similar examples of this that happen with everything else including imaging, labs, and diagnostic testing. When admitting patients as a hospitalist, I had to make sure I ordered lots of testing, meds, and labs to meet the "intensity of service" requirements the insurance carriers demanded to justify paying for an admission. This just raised the cost. The false assumption is that if a patient is admitted and the orders are minimal, must not be that important. Tell that to the young mother who quickly went septic due to group B strep infection. She didn't look sick on paper, but looking at her clearly something was wrong. The ER doc made the right call and I just admitted her, making sure I ordered as much as I could think of.
But insurance companies will rightly argue that, according to the contract, they can choose what and what not to "cover." The policy premium is based on what exactly is covered. From their point of view, you can't pay a specified premium and then demand additional coverage for things not agreed upon in the contract. Ultimately it is up to the patient to come up with the financial resources to pay for the physician's recommendations. Then arguments such as yours, that the insurance company is deciding care based on coverge are made. Technically they are correct and will vehemently defend their position. However, two points. In the insurance company contracts I have read and signed, there is always language to the effect that the insurance company has "final medical decision making authority." In other words, your "preferred provider's" medical recommendations are incident to their determinations of medical necessity. This is speaking out both sides of their mouths. If they only make coverage decisions and not medical ones, why do they control final medical decsion making authority? It makes no sense to me. Second, pharmaceutical companies can profiteer because insurance companies pay for medication directly. This allows for exorbitant costs, which many people can't afford, so they get insurance to help.
In conclusion, someone has to control costs and insurance companies, in my opinion, are ineffective at it. But right now, that authority rests with the insurance companies and they will control costs as they see fit. If patients want more flexibility and stability of coverage, then that would mean taking more responsibility for making decisions and resulting outcomes. To be brief, current attempts at getting patients to have "skin in the game" or take responsibility, are too simplistic and don't work. I believe there are ways to get patients engaged in their health care, with resulting decreased costs and true improved quality. But that is too much to discuss here.
Dr. Mike Henderson
Dr. Henderson.
Dr. Henderson.
Thank you for your considered reply. I agree with your opinion. I think the cost containment argument is valid for a couple different reasons, some of which you mention here. However, when an insurance company has a policy of forcing (refusing to pay for) a patient to continue thier current medication a given number of patients will simply decide to use to the new medication. Sometimes this is because it's a pain to switch back along with the accompanying physical side effects, sometimes it's because the patient cannot afford the cost or the time for additional doctor visits and frankly sometimes because the new cheaper medication works generally as well as the more expensive version. A given number of those people "forced" to switch will not undergo the pain of making the switch back. This is simple statistics. Each patient the insurance company manages to keep on the lower cost medication is a win for the company profilt margin even for those patients who have some negative outcomes from the new medication. The negative outcomes must outweigh the real/perceived cost of the process to switch back to the first medication.
If 20% of patients will remain on the lower cost drug that is a given number of patient cost savings for the company even if the consequences are somewhat negative for the patient.
The other issue I have with "remote medicine" is medical decisions made without patient contact/participation. Most patients receive a simple letter in the mail stating what the insurance company will do and what new drug the patient must now take. There is no physician contact to evaluate the appropriate consequences of the new drug. Just a different prescription at the pharmacy. I doubt many doctors would choose to practice their medical art remotely never seeing the patient and only basing their prescription decisions simply on what chart notes have been provided. This is what an insurance company does in these situations. They know the partient by electronic notes alone when the physician most often knows them personally.
Jeff Duncan
