How political agendas erode the doctor-patient relationship

Your doctor’s exam room is getting overcrowded. Modern US health care means that, like it or not, you and your physician are sharing that once private space with an insurance executive constantly hissing in your doctor’s ears to move it along. You are also sharing it with pharmaceutical marketers,  lobbyists from the food industry … special interest groups of every stripe.

Now move over and make room for one more interested party:  your employer.

Ever since the HHS ruling last month that employers cannot exclude contraception from the preventive services that their insurance plan covers, the country has worked itself up into a fever of self-righteous indignation, framing the controversy around women’s rights, religious freedom, and political posturing.   As a doctor, I see it see it through a different lens.   I see the primary symptom of our dysfunctional health care system as being the unrelenting erosion of the doctor–patient relationship – a relationship that is central to health and healing.  And I see this latest distraction from meaningful health care reform  - an employer’s wish to define what kinds of access to health care are appropriate for his employees  – as just one more assault on that very intimate and healing dynamic.  Now, in addition to trying to shut out the noise from all the parties that want to make a profit from your visit, doctors  now have to consider, “so what does your employer think of all this?”

How many more parties are we willing to invite into the therapeutic conversations we have with our health care professionals?  If a CEO of a major company is an anti-vaccine activist can she refuse to let her company’s health plan cover routine immunizations for children, as a matter of conscience?   Could an animal rights organization like PETA refuse to allow coverage of chemotherapy regimens that relied on animal research, based on that group’s deeply held convictions? Recently the governor of Virginia called for legislation that would require women to have vaginal ultrasounds before undergoing an abortion.  It used to be that you had to go to medical school before ordering an invasive medical test; now apparently all you need is political ambition and a microphone. In our current divisive political climate, the conversation about our health care has become less and less about what is happening between doctor and patient, and more about what individuals or groups want for themselves – and don’t want for the rest of us.

We will know that our health care system is functioning well when the one overriding question that drowns out all the other noise in any doctor-patient encounter is this: What is best for my patient?  We can measure our health care system – and our society as a whole – by how hard we make it for health professionals to ask and answer that fundamental question, whether it be due to punitive financial pressure, marketing strategies or political agendas.  Cost effective healthcare can only result from sound health policy.  The role of political leaders is to recognize and implement sound policy, not define it.  Meaningful health care reform will require that all the self-serving noisemakers, from pandering politicians to profiteers, and yes, even people of deeply felt but not widely held convictions, get out and stay out of the exam room.   If we fail to do this, the doctor and the patient will end up having the smallest voices in the room.

Maggie Kozel is the author of The Color of Atmosphere: One Doctor’s Journey In and Out of Medicine and blogs at Barkingdoc’s Blog.

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  • Marc Frager

    what is best for the patient is private care without insurance, government, or other bureaucratic interference

    • Ophelia Chang

      I would argue that what is best for the patient is the option to seek private care when there is a not-for-profit private insurer available. In the absence of a not-for-profit private insurer, citizens should be allowed to choose a government-provided option, like Medicare, for a reasonable premium. The for-profit insurance industry can not have a patient’s best interest in mind while being accountable first to its stockholders. As a physician, I will be one of the first to sign up for a public plan fashioned after Medicare.

  • Jared A. Chambers

    Yet another self-righteous piece demanding that politics be removed from healthcare…. or else the government should step in and make it so!  Yes, third party payers controlling 90 cents plus of every dollar spent on healthcare has negative consequences.  When the payer and consumer are separated, the market is destroyed.  The answer is obvious… the consumer needs to have a vested interest as the payer.  What can do that?  HSAs and high-deductable plans.  Allowing individuals the same tax advantages as employers in buying insurance policies.  Let insurance be bought across state lines.  You don’t ensure anyone’s doctor/patient relationship by mandating that I buy a policy that has things I don’t need or want that someone still has to pay for.

    For too much of the medical profession, true patient empowerment IS a problem… they might start comparing doctors and options.  They might tell their doctor to take a hike for a $300 fee for 5 minutes of time an a script for amoxicillin, all to pay for some other service performed elsewhere at a loss because of an arbitrary CMS-set cap.  If you want the politics out, then get government OUT.  Anything short of that is simply demanding politics other than your own to get out.

    • Lumi St. Claire

      I appreciate Jared’s point of view, and I’d like to offer a somewhat different perspective.  Putting the issue of government involvement aside for a moment (agreed, technically it’s impossible), I think we have to take into consideration that perhaps medical care shouldn’t be a capitalist venture at all.  We currently have 47 million uninsured Americans in this country.  We also spend more far more money on health care than any other industrialized nation on the planet, and yet have some of the worst healthcare outcomes.  Perhaps if we viewed healthcare as more of a right and less of a privilege, we could attempt to build a model that supported the provision of care instead of the denial of it.  Feel free to accuse me of indulging my inner hippie – I’m fine with that.  It’s just that if we continue to operate in a model that financially rewards top level executives for withholding health care, we can’t be all that surprised that ultimately we are not taking the best care of our health.  

      ~Lumi St. Claire

      • Jared A. Chambers

        I wouldn’t go so far as to accuse you of being a hippie!  However….

        Rights are something natural that you are born with.  You cannot, by definition, enjoy as a right that which requires another to sacrifice a right of theirs.  Now, that’s not to say that you don’t have a right to pursue means to obtaining healthcare, food, shelter, or any necessity.  In fact, this very government interference has obstructed that natural right, because I am not treated equally under the law if i want to opt out of an employer policy to buy my own, I’m restricted as to where and from whom I can obtain coverage, and what I pay for services has less to do with me and my doctor than what some bureaucrat decided a certain DRG is worth.

        If we spend more than any industrialized nation on earth, then it is worth noting that more than 50 cents out of every dollar is paid by the government through Medicare and Medicaid.  In other words, it already IS NOT a capitalist venture.  Interestingly, as the government’s share of end-user costs has grown, so has the overall cost.  The rest of the third-party payer system that covers the next 40 plus cents of every dollar is drug along by the Federal Government’s decisions on what procedures are worth.

        It’s easy to demogogue insurance company “top-level executives.”  But it misses the point to run to Congress and the Federal Government as people to fix the problem when they already have had a greater negative impact than these executives.  If the role of third-party payers had not been expanded by the Government, then your first consideration in care would never have been a bureacrat’s (public or private) potential denial of a claim.

        • Lumi St. Claire

          Very interesting, and some good food-for-thought.  Consider this for a moment though: as a 30-something upper middle-class American, I do not qualify to participate in either Medicare nor Medicaid.  There are millions of Americans just like me.  So while I co-exist with a system that is substantially funded by the government, it is not my health system.  My health system is entirely third-payer driven.  And in 2009 alone, a piece of the insurance premium payment from every American covered by Cigna went toward covering their $136 million dollar CEO transition package.  Not toward funding actual health care. And as far as decisions regarding what procedures are worth, in the non-Medicaid and Medicare system, that is being decided administratively by individual insurance corporations.  Which is why an EKG “costs” ten different amounts in ten different insurance plans.  

          I don’t pretend to have an answer to any of this, especially given that we are so firmly grounded in a profit-driven model for health care.  Regardless of whether you view seeking access to health care as a right or a privilege, it’s certainly not working for the vast majority of us the way it is right now.  

          • Jared A. Chambers

            I appreciate your approach… and by the way, enjoyed perusing your blog.  I have an agreement…  that the majority of Americans are slaves to a system that is controlled by a service for the minority.  It turns out that the old and disabled use a disproportionate amount of care, so account for a higher spend.  Most people have no clue about that, because they think of Insurance companies being the predominant third party payer because it is what most of us use.  I also have another agreement… either public or private, for most of us the system is third party driven.  It would be nice if I could ditch an employer plan that didn’t meet my needs and by my own, but I am at a disadvantage.  It would be nice if I could use insurance only for dire circumstances and use my own HSA money instead, but government and insurance companies collude to make that harder, not easier.

            I’m not defending insurance companies, because how can you defend companies that collude with the government to gain advantages and keep down competition?  That may be big business, but capitalism it is not.  But, in the end, we’re all born capitalists… we do what we percieve in our best interest, whether an outside influence has warped the system or not.  If we perceive that someone else foots the bill, we use more medical service without assessing its real value.  if the insurance company perceives it pays the bills but doesn’t get the benefit, it tries to avoid paying as much as possible.  If the government thinks I will vote a certain way that empowers them, they’ll take your money that you earned and give it to me.

            And being born capitalists, math tells us it will win over time.  The only short-term sustainable model for providing care to all without regard to costs is the single-payer model that’s been tried, where, on paper at least, we all pay in the same amount and take as we need.  But in the long term, the reality is that we don’t all pay in the same amount even in taxes.  One further removal of perceived value from perceived cost will do what we have seen happen already…  higher use (who cares the cost.. I already paid… except I may not really have paid), higher taxes (it gets hard to fund that higher use when only half are paying taxes, anyway), rationing (eventually use surpasses revenues), and ultimately, collapse.

            We’ll end up in the same place no matter how much pain we first endure… patients must have a vested interest in the direct cost of care.  That means reform for Medicare and Medicaid that move toward models that allow for those who chose to not use medicare as the direct payer of claims, and it means empowering those of us… virtually all of us… who find our employer plan doesn’t fit what we need (it either costs too much because it provides services we don’t use or want, in my case as a thirty-something unmarried male) or because it doesn’t offer enough options at any price point (especially those with families), to go out and buy our own policies, from any provider, without being at a tax disadvantage.  It won’t overnight (or maybe ever) return to a true free market, but those market reforms stand a better chance of working than offering universal care at a lower premium and expecting prices to drop.

          • Anonymous

            Perhaps clarification of the purpose of insurance is in order – actuarially based distribution of risk.  You may be concerned about services that you do not use, but the COVERED POPULATION must have them available.
            Egregious benefits to the administrators, such as the earlier cited CIGNA CEO payment, are disturbing, but the capitalist would say that is the cost of obtaining the best talent.
            Frankly, what disturbs me the most is the psychology underlying the term insurance companies use for the percent of premium money paid out for patient care – “medical loss ratio”….

  • Anonymous

     “An employer’s wish to define what kinds of access to health care are appropriate for his employees — as just one more assault on that very intimate and healing dynamic.” 

    Huh? How does an insurance plan that does not cover contraceptives because of the employer group that it covers, deny women access to health care? It does not deny women access to Pap smears, pelvic exams, or mammograms. The woman can still easily get contraceptives; they are just not covered by the insurance. 

    • Brian Curry

       It denies women access when oral contraceptives are prescribed for disorders like PCOS or dysmenorrhea. These women are forced, then, to either A) pay for their own treatment because of their employers’ moral objection to their use in an entirely different application, B) go without treatment for the same reason, or C) disclose their medical problem to their employer in order to have the treatment covered under an exception.

      But this isn’t the point. You’re absolutely right, it would still be available, just not covered. That’s why the rule was issued in the first place. According to the rule, now it IS covered, regardless of employer. Challenging the rule on 1st Amendment grounds seems likely doomed to failure.

  • Maggie Keavey Kozel

    Interesting comments.  Where I differ from those with opposing views below are in two main areas.   Both revolve around  the idea that we shouldn’t have to pay for someone else’s health care.  So first, everyone needs health care. Someone is going to pay for that care.  If we don’t have a plan, than we all pay top dollar when an underinsured patient waits too long and goes to the ER or accesses care in some other expensive way, with something that could have been prevented.  Secondly, the question of whether or not health care is a right disturbs me.  I would instead ask, given the tremendous medical resources that this country has, what responsibility do we have as stewards of that resource, to see that it is used fairly and humanely. 

  • Jim Jaffe

    while you’re certainly free to imagine an idyllic past before those who pay the bills got involved, history suggests otherwise.  government got involved, notably via medicare and medicaid, because an unacceptably high percentage of the population wasn’t getting care because it was uninsured and couldn’t pay for it.  since then the uninsured segment has declined while health status has improved and lifespans have lengthened.  employers got in when they realized their premiums were outpacing wage increases.  they invented managed care, which has moderated increased costs while the positive trends noted above continued.  so from my perspective it looks like problems in the system brought these folks in, albeit at the cost of new problems.

  • Greg Mercer

    Physicians and other care providers need to start using their reasoning skills, tenacity, and proven ability to work under adverse conditions to find solutions to all the systems problems we face.  Providers played their part in creating current conditions: by making health care so massive and lucrative – nearing a full fifth of our economy and growing! – interference from pols and MBAs is inevitable.  We can merely regret the results, complain about them, or we can contribute to solutions.  The current status quo in untenable and worsening each day: will we wait for the entire system to collapse when the nation can no longer subsidize it, or will we think and act?

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