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Tuesday, May 20, 2014

What matters more?

I've had the opportunity to think about several things this past week, but among the more distressing is where we're headed in the game of "who is my doctor?" Now, as a physician myself, you would think that it would be easy for me to pick and choose. But I'm here to tell you - that is not the case. I can think  of a lot of practitioners out there to whom I wouldn't take a sick hamster. There are also those who would do "in a pinch," but to take myself or my family member to on a regular basis, and expect competence, caring and availability - those are truly rare. And to make matters worse those few are exceedingly busy. And I understand that this problem is nationwide.

There is a history behind this dreadful trend. And that history is one that is spelled out in dollars. What has happened?

Let me take you back to a time before DRGs (more on that later). It was a time when medical schools produced doctors who were ready to take on the challenges of practicing medicine in the real world. Ready to work, to be busy, to work long hours. It was a time when billing was much easier, requiring far fewer people. And it was a time when even those with no insurance could get high-quality care, without going bankrupt. It was also a time when you knew who your doctor was, and that he/she cared enough about you that if you had an after-hours emergency need (come to think of it, most emergencies occurred after office hours), that he/she would be there for you. It was a time when urgent care centers did not exist (did not need to exist).

And it was a time when hospital care was much more relaxed, and by today's standards, much of what was done in the hospital "could have been done on an outpatient basis." The insurance companies paid for claims that were submitted, and it seemed that no one was too concerned if the patient stayed an extra day or two longer, because they needed some more physical therapy, or because they were too weak to make the trip home. But that was the good news.

It seems that somewhere around 1980, someone was looking into the costs of Medicare, and noticed that they were going up (though by no means were they skyrocketing, as in later decades). And it was the brilliant insight by a clerk (in New Jersey) that doctors could be made to reign in the costs of hospital care if we just went to a DRG payment system. DRG stands for Diagnosis Related Group, and by limiting payment to a specific diagnosis, medicare could then simplify its payments, and not have to pay for all those other related diagnoses. And hospitals could then put the pressure on doctors to "just treat the one condition the patient presented with."

Well. this was just the beginning, and soon other major insurers jumped on the DRG bandwagon, and thus began the decline of medicine as practiced in our country. The idea was to save costs, but costs, as you know have gone steadily upwards. There had to be more people hired by hospitals to do the billing, and there had to be more people hired by the hospitals to make sure that their bills were "in line" with the ever more confusing and changing regulations. And on the other side of the spectrum, Medicare and the big insurance companies also had to hire more people to handle the increased paperwork demands, and to make certain that no one was cheating the system. And all these extra people came at an exorbitant price. And to make matters even worse, now the insurance companies, the hospitals, and (of course) the government now require legal teams to oversee everything, and to make things so much more obtuse.

And so, what about doctors? Well, a physician can no longer afford to just hang up a shingle and practice medicine. He/she gets paid less and less for more and more work, and has to have an electronic medical record, both in the hospital and in the office. The physician has to have someone with computer skills and "coding skills" in his office, as well as someone to keep track of Medicare and its monthly changes.

I think you begin to get the picture. We were never taught computer skills, Medicare-negotiating skills, coding skills. What we were taught was MEDICINE. We were taught how to take care of the ill and afflicted, and we were now swimming upstream against this incredible current.

So then, what have doctors done? Well, the few who remain in primary care have had to limit their practice in a number of ways. For one thing, they don't take care of patients in the hospital - they turn that job over to hospitalists. They have to severely limit the number of patients seen per day, because there is no other way to do the required computer records. They have, as a result, become employees of the big government/big insurance companies, whether they realize it or not, and have taken on the mentality of employees. When can I go on vacation? How many hours did I work this week, and do I get extra pay if I work more hours?

And lost in all this folderall is the patient, who longs for someone with the gentle touch of experience, for someone who knows and understands me, for someone who cares. Someone who can see through all the blather and institutional malarky, and explain to me in simple terms why I hurt.

So then, what matters to you as the patient, for we all become patients at some point?  How badly do you want it, and how much are you willing to spend?

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