Ideal Medical Practices

Primary care shortage, ethics, and the elephant in the room

MSNBC has been making some noise recently about primary care physicians going off the grid to provide better care for patients who pay directly for services:

Patients face bitter choice: Pay up or lose care
Clinic with two doors, a symbol of two-tier care
Opinion: ‘Concierge’ is another word for bribe

The statements are stark and harsh:

• Getting a doc's time and attention shouldn't require a premium fee
• No one should have to pay more to get decent, unhurried and attentive care
• The whole system of primary care has broken down

I couldn't agree more.  It infuriates me that the choice offered most physicians is between maintaining the status quo of low quality high volume care or exacerbating the physician shortage by downsizing, charging premium fees to deliver high quality to the few.

I've spent years studying the medical office practices and lead a national demonstration project showing how far we can go in delivery excellent care.  The results are everything we want and need - high quality, terrific experience of care & bending the cost curve. 

The problem is that this work is not valued in our current system.  Docs who deliver high quality care, docs who provide decent, unhurried & attentive care are punished financially and end up losing their practices as they re-enter the indentured servitude of industrial medicine.

I've spent years trying to get the payers to provide the resources necessary to achieve & maintain high quality care.  Everyone professes interest but pay only lip service.  What makes me want to tear my hair out is that the extra primary care funding results in total costs substantially lower than maintaining the status quo.

I hate that we're forced into this dilemma:

Maintain the status quo while study after study demonstrate bad outcomes, lousy experience of care and outrageous high costs.  Maintain the status quo that creates a prison-like atmosphere for primary care with docs in such abject misery that few medical students choose to enter primary care.  Maintain the status quo that is the very root cause of the primary care shortage.

or

Do what we can now to deliver high quality care.

I know there's always a middle course, but right now I applaud those doctors who choose a path of quality in the face of misinformed accusations of unethical behavior.  These practices are not holding their breath for health care reform that gets it all right.  Many have taken the less traveled path to demonstrate that:

• High quality can be achieved now
• Primary care can be an excellent career choice
• Physicians can get out of jail and control their professional lives

Health care reform is a messy process during which we will see good ideas with unintended consequences.  These docs are choosing to serve fewer people well & Congress is choosing to continue to leave millions of Americans out in the cold with no health coverage.  Rather than lashing out let us work together to bridge these gaps so that we can live up to Dr. Cohen's comment:

The truth is, we all deserve the kind of attention from our doctors that our grandparents routinely expected and their doctors routinely supplied.

Amen to that. 

Let's get back to a place where the doc didn't have to spend hours every day feeding the administrative trivia beast, playing 'prior authorization' and 'billing and coding jeopardy.'  Let's get docs off the hamster wheel and give them the breathing room they need for decent, unhurried and attentive care.

I want the health insurance industry to stop torturing me and my patients

I’ve struggled for a long time with the idea of charging patients directly for payment.   There’s just too much evidence that asking people to have “skin in the game” creates a serious negative pressure resulting in avoidance of needed care.

A recent article in the NYT points out the pitfalls of high deductible plans – the most worrisome pitfall is wealth of evidence showing that people avoid spending their dollars on care that might have prevented illness or allowed for earlier diagnosis and intervention. 

So direct to consumer/”skin in the game” health care creates a financial hurdle to health care that too many people are unable to clear (and don’t tell me “they would clear the hurdle if they really cared” because the data just doesn’t support that statement – too large a swath of the population goes without needed care.  To assume that that large a swath ‘just doesn’t care’ begs credulity).

On the other hand, ditching the insane costs, rationing, delays, and choice limits imposed by the insurance industry creates the capacity to practice highly ethical medicine for patients.  Continuing to accept these outrageously harmful insurance company rules enables a broken and dysfunctional system to continue.  Some (not all) of the coolest innovations in health care have been possible in practices that ditch the crushing yoke of insurance rules.

This is an awful situation.  I want all Americans to have unfettered access to highly ethical high quality care.  I know we as professionals want to deliver this care.  Until the insurance industry is willing to stop blocking our work and actually support the outcomes we need, I just don’t see a way past this dilemma.

Which path will we as professionals choose: the wallet or what's best for our patients?

I just read Atul Gawande's piece in the New Yorker.

Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can. But we have to choose someone—because, in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.

As a profession we have a choice.  The choice between doing good and doing well is false.  I choose both.   I believe the ethical practice of medicine is ultimately consistent with doing well as a professional.

Health insurance policies at the moment force us to choose between doing good and doing well and this is wrong. I have to choose between working outside of insurance and delivering highly ethical health care to the few who can afford it or take the insurance company strictures that force the unethical practice of medicine.  This is wrong.  We need a better way.

We have sacrificed the people we serve on the altar of ‘economies of scale.’

For years health care has been caught up in the notion that we can be better business entities if we pursue the principle of “economies of scale.” 
“We can have one person answer the phones, another do the check-in….”  It all seems to make so much sense – I mean, isn’t this efficient?

We see large practices that have many staff and have large waiting rooms (more economical than several small waiting room, right?).  We have billing staff, referral staff, managers to help manage the staff.

Because of all the people, we have to hire human resource staff as well.  We purchase an EMR so that we can code better and wring every blasted penny we can out of the insurance billing craziness.

What gets lost in this?  The people we serve. We become institutions and the care becomes impersonal.  We then struggle endlessly trying to get “patients” to be “compliant” with our wonderful evidence based guidelines and protocols.  “I have this 60 year old diabetic that just won’t listen to me – I am just so tired of this non-compliance!”

We have sacrificed the people we serve on the altar of ‘economies of scale.’  When we wake up from the nightmare we have created we have to tear down the walls we have built to keep the ‘patients’ at bay.  For our recommendations to have meaning in the complex lives of those we serve we have to slow down and actually listen to people.

The benefit of knowing patients as people and treating them with dignity and respect is profound.  Economies of scale erode the very foundation of the ethical practice of medicine unless sequestered to parts of our work that do not impact the personal relationship.

L Gordon Moore