There are an awful lot of reasons that led up to my eventual resignation from a career in primary care medicine. I don’t know that any one of them is more important than the other (it really just depends on which day you ask me). One that stands out for me though as a universal problem shared by millions is Managed Health Care, and the imposition it has posed on physicians and patients alike is enormous.
A (mercifully) brief history of managed care: The origins of the first managed care efforts in this country date back to the early 1900’s, when prepaid physician services started showing up in a few select industries and health care organizations. In 1947, the American Medical Association was walloped with an anti-trust violation for their efforts to limit physician involvement with group health plans. The movement gained momentum and really got some teeth when President Nixon signed the HMO Act of 1973 into law (way to go, Dick). This provided a legal avenue for using federal funds to promote the growth of Health Maintenance Organizations. The backlash really caught up in the late 90’s, when US per capita spending started to rise again, despite the mission of managed care to reduce heath care costs. US healthcare expenses continue to eclipse the national income, and have been increasing approximately 2.4 percentage points faster than the annual GDP for the past forty years.
Ironically, while the whole point of managed care was to reduce healthcare expenses in this country, insurance company executives have continued to earn grossly exorbitant salaries. The top executives working at the country’s five biggest for-profit health insurance companies earned compensation of almost $200 million in 2009. Cigna insurance company paid its outgoing and incoming chief executives a combined $136.3 million that year. And for all this, we still have the worst health care outcomes compared with six other leading industrialized nations.
Now you have to layer on top of this healthcare cost crisis the fact that doctors have really had to change the way they practice medicine. Managed care means less time spent directly with patients, and more time spent on non-clinical activities (i.e. paperwork). The 2011 Medscape Physicians Compensation Report generated survey results from almost 16,000 physicians across 22 specialty areas regarding income and practice parameters. Primary care physicians have the shortest access time per patient, with a median visit time of 13-16 minutes per patient. (For the record, pediatricians averaged more patient visits per week than any other specialty.) 17% of primary care docs spent more than 20 hours a week on paperwork and other non-patient activities, and less than half of primary care physicians would choose to go into primary care again if they had the chance to do it all over again.
Quite honestly, this turns my stomach. And I already got out of clinical practice.
I remember my own horror stories perfectly. Like the day I spent six hours on the phone with an insurance company trying to get one of my patients a badly needed MRI. I also had one insurance company deny authorizing my patient an EpiPen. As medical professionals know, EpiPens are automatically-injecting syringes pre-filled with epinephrine that patients carry with them who have life-threatening allergies to things like bee stings, peanuts, etc. They keep people from dying. I could not imagine on what planet and in what solar system an insurance company would have a sane reason for denying a severely allergic patient one of these. And the worst part was they absolutely had to talk directly to me about it. They couldn’t discuss it with one of our residents, our nurses, or our nurse practitioners. I had to take time out of my excruciating schedule to have a lively chat on the phone about why it was important for my patient not to croak.
This is a crime. I did not pay a small fortune and spend four years in medical school to be trained on how to deal with the insanity of managed care. And I don’t think my patients would have wanted me spending precious time learning how to appropriately fill out an authorization form, when I could be learning about medical disease processes. Yes, people are specifically trained to deal with managed care, but often enough the insurance companies demand explanations from us that they simply won’t accept from other staff. And if we don’t comply, our patients are the ones that pay the price. If I put my foot down and say it’s inappropriate for an insurance company to require I give a pharmacy my DEA number just for tracking purposes, my patients simply won’t get the medication they need.
Having recently retired myself from clinical practice, I will be the first to admit I miss my colleagues. I desperately miss my patients (well, most of them anyway). But I don’t miss this. Not for one solitary moment. My heart goes out to my colleagues who are still trying to practice actual medicine in the face of mounting adversity. Keep fighting the good fight.
Lumi St. Claire is a pediatrician who blogs at My White Coat Is On Fire.
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