Friday, May 25, 2012

I know who to blame for why your doctor has no time.... -<br />Patients continue to complain that physicians don't spend enough time examining and talking with them.
There's a great story from National Public Radio, about why doctors have had to rush appointments (What's Up, Doc? When Your Doctor Rushes Like The Road Runner). The short answer? Doctors aren't paid to listen. Health insurance companies don't reimburse enough for listening. And in a lot of cases, believe it or not, doctors are running so close to the red, they can't afford to listen, as a result.

According to one infographic from the Wall Street Journal (and supported by the NPR story), it takes seven staff members for every single doctor. Can you pay seven salaries on your income? Remember too, that some of these salaries would have to be other health professionals, like Registered Nurses. This ain't no minimum wage gig. Now, remember that you're also going to have to afford a medical office space. There's no doing this job from home, and a regular retail space won't do... There are all sorts of heath codes and other business expenses. Now throw on top of this insurance costs (one of the highest groups, obstetricians/gynecologists could find themselves paying up to $64,000 or more for coverage, and that's for a spotless record), and suddenly that doctor's salary doesn't look so sexy. It makes perfect sense why more doctors are trying to cram us into 15-minute visits.

Inside a Medical Practice - Family practices like Westminster Medical Clinic [Colorado] are struggling with new ways of delivering and paying for primary care.

I know exactly who to blame for this too: Harvard economist, William Hsiao.

See, as Medicare goes, so go the insurance companies. And he was the guy who changed the payee system for Medicare. He came up with a new model in the 1980s. This model determined how much a doctor got paid, based on how difficult a task it was, modified by how expensive their education was to know how to do that task, modified by how much stress and/or risk was involved in the task. (Check out the book, Next Medicine: the Science and Civics of Health, for a more complete history.) Listening? Not hard---if you don't come to med school knowing how to listen, you probably shouldn't be there. Amount of special "doctor training" needed to know how to listen? Zero. There are no med school classes on listening. Stress involved? None... at least not when comparing it to anything else, and especially not as stressful something like trauma surgery. Risk involved? None---no one as ever been killed from listening. Payout by insurance? Let's see... Nothing, multiplied by nothing, carry the nothing, comes out to... nothing! (Big surprise.) The same goes for reading files, and organizing care following a major procedure. Doctors don't get paid for these things, so they turn into low priorities. Low priorities, even though these are possibly the most important parts of medical care: gathering information so you know what you're dealing with, and disseminating information so that things are done right!

But "how important is the task?" never mattered to Dr. Hsiao. It's not his fault, really. For one, everyone underestimates good communication and documentation... until they need it. (It's why I get paid so much as a technical writer.) And second, Dr. Hsiao wasn't paid to care either! The government signed his checks, and the government was looking for ways to save money. Dr. Hsiao was paid to come up with ways to save the government money on health care. The easiest way to save money? Don't spend it. The next easiest way? Find a way to pay less for the same things. The only problem with this, it changed doctor behavior. And it changed medical school behavior too.

Let's say that you had the opportunity to be a race car driver. You had the skills, the talent, and the changes in life, that now you're going to get paid to break the speed limit. Only, before you graduate from racing school, you have a choice. You can go race a Formula One car, with all the fame, money, and hot babes screaming for your autograph. Or, you can go race a banged-up economy car, at some obscure county fair, with 5-year-olds screaming (not for your autograph... just screaming because they're five). Which one would you choose? Now you understand why there's a national shortage of General Practitioners. Although 56% of patient visits in America are primary care, only 37% of physicians practice primary care medicine, and only 8% of the nation’s medical school graduates go into family medicine.
The United States healthcare system has been facing a decline in its primary care workforce, infrastructure and access to primary care services for several years. A number of factors, including poor reimbursements to primary care physicians, low comparative income, and poor quality of work life due to high patient loads, have contributed to more doctors choosing to train and practice in specialty medicine. This trend has lead to a shortage of primary care providers across the country—likely contributing to fragmented care, inappropriate use of specialists, and less emphasis on prevention. (Study by the Henry J. Kaiser Family Foundation)

Which really begs the question... Why are we looking to the government to fix the problems of health care, when government is the one who made the health care problems in the first place?? They took a three-legged pig and turned it into a porcupine!

(Okay, I see your look... let me explain.)

Say you've got a three-legged pig. Poor thing doesn't walk so well, so here comes along a guy, and he says he's got this great solution! Stick on an artificial leg. Only the artificial leg doesn't work so goo either. It helps out some, but in other areas, the pig is still as broken. The great solution? Stick on another leg! That will help cover the deficiencies of the first leg, and make up the difference. Only that's not enough to make the pig normal either! Stick on another leg! And another! And another! One of these fixes is going to work someday!!! They do this, until the poor creature has so many artificial legs dangling off of him, it's no longer a pig, it's a porcupine.

Now, I'm not suggesting we do some sweeping change to wipe the legs off this pig. That's just a metaphor. But in trying to fix this problem, do we really want to go back to the group of people who thought it was a good idea to do it this way first place? We've been working on fixing this "health care" problem since the introduction of Medicare in 1965... And what was the result of that sweeping change? A doctor in the 1950s could expect to make three times more than a teacher. Nowadays? General practitioners make 3.5 times as much as a teacher, on par with 1950s rates. But doctors that specialize? Those doctors make six-and-a-half times more than a teacher.
"In 2008, physicians practicing primary care had total median annual compensation of $186,044, and physicians practicing in medical specialties earned total median annual compensation of $339,738." (Bureau of Labor Statistics Occupational Outlook Handbook 2010-2011 Edition, Physicians and Surgeons)

"For high school teachers, median salaries in 2007 ranged from $35,000 in South Dakota to $71,000 in New York, with a national median of $52,000." (U.S. Department of Labor: Bureau of Labor Statistics. (August, 2007). Spotlight on Statistics: Back to School.)

Good work, Dr. Hsiao! Even though 60.5% of visits made are made to primary care physicians, and even though the most frequent principal reason for visit is a general medical examination (National Ambulatory Medical Care Survey: 2008 Summary Tables, tables 1, 9, 13 [PDF - 478 KB]), the government has guaranteed that there will be fewer primary care doctors available. Additionally, the government has guaranteed those doctors will be pressed for time, due to cost constraints.

If we want doctors to take time, they need to be reimbursed for their time. I don't know what the solution would be. But the solution to a problem caused by government, is not to add more government.

[Edited to Add]
Seems Peter W. Carmel, President of the AMA, has a similar notion:
The Medicare physician payment formula is a case-study in failed policy. Physicians have long known that it is not working. Polls show that an overwhelming 94 percent of Americans believe the massive cuts it schedules are a serious problem for seniors. Even members of Congress from both parties agree – and that is no small accomplishment – that it is bad fiscal policy and destabilizes Medicare. We now face a looming cut of about 30 percent on January 1 from the failed formula. (AMA: Moving past a failed Medicare formula to focus on quality care)


  1. All gps receive less pay regardless if it is medicare, medicaid or private insurance. Private insurance also inflates a specialty practice as well with regards to payment. Now, I for one don't have confidence in private pay insurers fixing our current system as they are driven by profit and profit begets encourages money as the primary - ROI or return on investment. Personally I believe that healthcare should be non for profit. Oh no...yup...non for profit. Just the thought of someone making a profit on the illness of another, the ability to cure, etc. etc. makes me sick! At one time Blue cross and blue shield was a non for profit in some states and did very well in coverage, etc. Then they went for profit and well...let me just say...the ROI rose, the payments decreased to service providers...well you get the picture. Now if a private entity wishes to splurge ahead as a non for profit (which they won't) I say horrah! But if we return to our old system of ability to pay in this country, we will never have a healthcare system based on successful treatment and health. Instead we will have the wealthy receiving top notch treatment while the rest of us receive whatever level of care our income will dictate. Personally I feel if we were to do a national referendum instead of 50 individual state laws for healthcare, that would cut government down substantially. I have not had issues with the federal government over the past 20 has been state and local governments that have strangled me to death both financially and law wise. Yup, do away with local and state mandates and make one law for this country. That would cut costs substantially and maybe open up true competition. And this is just my two cents worth :-) I respect your view as well and just wish a good healthy discussion would get started and come to some solutions instead of constant political bickering.

    1. Oh, I'm with you on the NPO...

      The wealthy will always receive top-notch payment, whether it's a socialized system or not. You can bribe you way in a socialist system, just as you can buy your way in a capitalist system. Money, power, and influence will always get better service. There's no getting around that.

      I agree that local and state are awful too. Wanna talk about over regulation? Yie...

      One system sounds nice, but you and I both know that health is not one-size-fits-all. What I would like to see is more fluidity in handling cases, so that more people can be served (in the way they need to be). That, by the nature of the beast, is going to have to be ad hoc and messy. Get the regulations out, and help people.