By Madhureeta Achari, MD
I read an article recently suggesting that physicians were burned out from hearing about burnout. The proposed solution was to create systemic changes to help alleviate the burden of complexities of care that have polluted health care delivery. The solutions involved adding a team of individuals, including nurse practitioners, physician’s assistants, pharmacy assistants, and other physician extenders.
Once again, rather than focus on the physician-patient relationship on which medicine is based, the “experts” continue to react to an unnecessary system that has been built around and profits from every aspect of health care delivery.
Physicians don’t need extenders. We need more time with patients and fewer redundant and pointless tasks. The answer is to reduce the complexities that have been consuming the time physicians should spend with patients.
These systemic burdens have been placed on physicians over a mere 40 years. They are not the way it has always been. They can be undone. This is a situation where stepping back and respecting the pillars of the medical profession is the best option. Understanding and bringing forward the essential parts of the practice of medicine — the human parts — and using current technologies to enhance patient care are the solutions.
Bringing physicians and patients together and honoring that relationship is the key to a positive change in American medicine.
These complexities are not only frustrating physicians. They are frustrating patients and are not helping our general state of health. The distractions of complex insurance contracts and payment systems have done great damage and continue to create anxiety and uncertainty in patients, not to mention the financial stressors that contribute to a lack of well-being.
Why do we pay so much for health care yet pay physicians less yearly? Why are the CEOs of insurance companies profiting while putting systems in place to make it harder for patients to get the care, treatment, and medications they need? Why are physicians having to spend more time with electronic medical record systems than with patients, providing statistical data for the government and insurance companies, or else they suffer the penalty of reduced reimbursements?
Why have government regulations created multi-layer reporting and billing systems that take care and control away from patients and physicians? Why are Medicare patients only allowed a single lifetime physical when they enter the system, limited yearly blood tests and minimal preventative care at the time of their lives when their health becomes more complex, requiring more attention? How on earth can we expect physicians to see a larger volume of more complex patients in less time to break even due to ever-lowering reimbursements?
Imagine a time when a patient was able to call and make an appointment with a doctor without being asked what insurance they had. The appointment was booked, a minimum of information was required, and the patient saw the physician without having to wait a month or more.
The appointment was usually in a small clinic setting. This is as opposed to a costly large-scale professional office building. These have now been proven to be unhealthy in our current pandemic world and lack any privacy for patients (what good are HIPAA privacy regulations when everyone knows what type of doctor you see as they walk down the hallway).
After the visit is completed, the patient could take their prescription to the pharmacy and have it filled for a reasonable cost. If imaging or bloodwork were necessary, many doctors had X-ray machines in their offices or had joined together in a cooperative arrangement to have an imaging center or laboratory where patients could get testing done at a reasonable, transparent price.
In this model, many people could afford regular doctor visits without breaking the bank. The insurance models were indemnity plans with simple deductibles that asked the patient to pay 20 percent, with the insurance covering 80 percent of the cost. By the way, the patient paid at the time of the appointment and was given a superbill to file with their own insurance for reimbursement.
This uncomplicated, user-friendly system worked well for many decades. In the 1980s, the first step at governmental regulation came into being to create a maximum allowed acceptable rate for Medicare charges, and the relative value unit was born. Then came the Medicare HMOs, which controlled a patient’s access to care without ever fulfilling the promise of improved health and reduction in costs.
Managed care clinics have been in existence for many years. Some, such as Kaiser Permanente, have done a good job providing complete care for patients with a systematic approach to health care. Conversely, the managed care systems administered by insurance companies, whose main motivation is profit, have made a killing by delaying or denying health care to patients. As physicians, we made the mistake of signing contracts that gave our authority to an opaque, layered bureaucracy that is now at the heart of what is troubling us and needs to be dismantled.
This same corporate practice of medicine lacks respect for the physician-patient relationship, which is now trying to insert other layers of less-trained providers between physicians and their patients.
Yet, corporate analysts claim that this layer of physician extenders will improve patient satisfaction and care and free up time for physicians. This is a fallacy — no patient wants less time with their doctor.
How do we carry forward the best of the tradition of medicine and incorporate the new, modern, and ever-changing aspects of the world?
I have seen medicine practiced well for many years on three continents in various settings. I am the granddaughter of a small-town physician in India and the daughter of two physicians. My mother practiced obstetrics and gynecology in India and England until the early 1970s. My father is a neurologist who trained and practiced in academics and had independent private practices in India, England and the United States.
The one clear commonality in the delivery of quality care in a satisfying way for patients and physicians is time. You can’t make more of it, and distributing a patient’s time amongst a variety of lesser-trained individuals does not promote quality. The appearance of time with your physician is not the same as actual time with your physician. Smoke and mirrors don’t work in medicine; there is too much at stake.
It’s time to step back and take a good look at what is working and what isn’t. It’s time to bring back the essence of care, the physician-patient relationship, and place it at the pinnacle of any model.
Let’s ask which elements of our system support this and promote and enhance those elements. If anything takes time or focus away from the main principle, let’s remove or replace it. Whether it’s the EMR, payment models, prior authorizations, or even automated phone systems, let’s rethink things so the two main people — the patient and the physician — are supported, and excellent care is allowed to be delivered with compassion, care, and time. Only then will we truly heal what ails us.
Published November 25, 2022 KevinMD.com