Doctors and patients are both losing in our health system

Early in my medical training I envisioned myself as an old-fashioned family doctor. Marcus Welby, MD was well before my time, but he seemed like a good fictional role model for a naive student-doctor. (Especially considering Dr. Cox of Scrubs was my alternate choice.) After finishing my primary classroom studies, I was eager to leave the stacks of paper behind and to learn from real clinicians caring for real people. After donning my short white coat (sans leisure suit), I quickly realized my romanticized vision didn’t mesh with my new reality.

As I advanced through medical school and into my family medicine residency, I was increasingly exposed to the “inner workings” of health care. Behind the scenes I saw much of the doctors’ time spent on issues other than patients’ health. Seemingly, the documentation about what they did took more time that what they actually did. My mentors frequently vented behind a mountain of charts about the decline of their profession. (Maybe the TV show just failed to show Dr. Welby filling out 5 pages of paperwork after he treated a simple sprained ankle?)

Hospital and clinic staffs consisted of small armies of people to do coding, billing, following up on denied claims, prior-authorizations and on and on. To financially support this administrative structure, the doctor(s) would take on more patients. The average primary care physician is now responsible for 2500-3500 people! I was frequently told “efficient” doctors could handle double and triple booked schedules – and it would be required to keep a private practice afloat. Unfortunately, this efficient pace allowed very little time to answer patient questions, educate about chronic diseases, calm somebody’s fears or listen to a patient’s bad joke.

During my training patients would frequently tell me about frustrations with their health care experience. While most people personally liked their physician, many felt disconnected and fed-up with the complexities of basic communication. After hearing the same stories again and again, I started to feel sympathetic towards these complaints. Despite our hard work and good intentions, medical practices often treated patients merely as vessels for billing codes. Doctors seemed to be unwittingly insulating themselves from the very people whom they committed to providing care. And this sympathy was directed towards the fortunate insured people with so-called ‘access’.

Don’t get me wrong, I met numerous amazing, compassionate physicians whom cared deeply for their patients. From my perspective, the doctors and patients were both losing in this system. I increasingly asked my colleagues, “Why do we do it this way?”, “Wouldn’t it be more efficient if ….” and other annoying questions. Usually my inquiries were met with puzzling stares and flippant answers such as, “Because this is just the way it’s done.” Despite everyone agreeing that the system “sucked”, all parties seemed miserably complacent.

Sure, many doctors were passionate about “reform” and had wide-ranging opinions about political fixes to our problems. I was encouraged to join (give money to) organizations, write representatives, march in the street, wish on birthday candles, etc., etc. But why should anyone be hopeful that such advocacy will be productive? Over the past 40 years, our country’s health care has been reformed by numerous rounds of bureaucratic acronyms -only to have theGordian knot become increasingly tangled. A perpetual Groundhog Day was not my idea of a fulfilling career.

I remain skeptical about any topdown solutions to our conundrum. I am not waiting for another round of regulatory tweaking to improve the value, access and quality of my professional services. We all deserve better, but we are not going to get it without some disruptive innovation from the grassroots. I believe doctors and patients can and should return to a direct, cooperative relationship for most health care issues. Maybe physicians never have been the caricatures from the golden days of television, but I’m happily and stubbornly naive. Something has been lost and we should fight to get it back again.

W. Ryan Neuhofel is a family physician who practices at NeuCare Family Medicine.  This article originally appeared on WellCommons.

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  • http://www.facebook.com/people/Ryan-Neuhofel/558505959 Ryan Neuhofel

    Kevin, Thanks for posting my piece. For more information about my direct-model family practice, go to http://www.neucare.net or http://www.facebook.com/NeuCare. The original blog is at . . . . http://wellcommons.com/groups/neucare-family-medicine/2012/jun/19/why-i-opted-out-my-decision-not-to-wait-/

  • http://twitter.com/chasethejohnson Chase Johnson

    Interesting read Ryan. Do you think the majority of physicians entering the market are surprised by the amount of “inner workings” there are or are some specialties able to avoid having that burden. I can imagine that the inner workings that you have mentioned are more prevalent in the private practice world vs. hospitals or other facilities, correct?

    • http://www.facebook.com/people/Ryan-Neuhofel/558505959 Ryan Neuhofel

      I’d say that most med students/residents are somewhat surprised to learn about the volume of documentation and costs of care, but much of it is “hidden” from our view in the academic world – which makes sense to a certain degree. The larger institutions (hospitals, large clinics, etc.) usually have separate, segregated offices (coding, billing, patient relations, etc.) dedicated to these tasks, so they are not as visible as in a small private practice. But, whether visible or not, they have far reaching impacts on how the system operates.

  • Melissa Carroll

    Great article. I’ve worked with a number of physicians around the country that feel exactly the same way and are looking to get out of the traditional model (now more than ever) and into direct pay, but struggle with the idea of planning and executing their escape. The third party pay system is completely out of date and puts a gulf between provider and the patient. I wish more doctors would make the leap to direct pay. They would have a better quality of life and their patients would benefit from the improved relationship. By the way love your website…

    • http://www.facebook.com/people/Ryan-Neuhofel/558505959 Ryan Neuhofel

      Thanks Melissa. I’m definitely taking a leap of faith with this idea, but I just didn’t see any other route to take. The Direct Primary Care movement has many variations, but I hope that docs continue to experiment with new models and challenge the status-quo. I designed the website myself, so thanks again! :)

  • sFord48

    I have the option not to carry health insurance but it is not a wise option, so I am stuck with paying premiums. I feel sorry for those primary care physician that don’t like what’s happening in the current health care system but I don’t more money sucked out of my pocket.

    • http://www.facebook.com/people/Ryan-Neuhofel/558505959 Ryan Neuhofel

      I’m not promoting people NOT carry health insurance. You are correct that it is not a wise option for anyone, regardless of age or health conditions. However, I feel the fully pre-paid, managed-care system – whether private or gov’t managers – is the root health care inflation. Every transaction that goes through a middleman (health “insurance”) drastically increases the cost of the service you ultimately receive – at multiple fronts. I strongly believe day-to-day, outpatient health care (“Primary Care” + ? more) is much better structured (cheaper, better quality) when paid directly from patient to doctor. Save insurance for expensive, unexpected events. Why should the payment system for the 1/million chance you need neurosurgery be lumped together with your family doc? In a sane world it makes no sense.

      • sFord48

        If you want to discuss your utopia, there are quite a few “routine” diseases that are very expensive. Are you suggesting that only PCP visits are direct pay or are the medications, the routine lab work, and the routine imaging included in that day to day, outpatient health care?

        Of course in our current system, money spent out of network is just extra money, even with a catastrophic healthcare plan, for those of us with chronic health issues.

        • http://www.facebook.com/people/Ryan-Neuhofel/558505959 Ryan Neuhofel

          My primary contention is that our third-party payment system makes things much more expensive than they need to be. Inherently, using a pre-paid third-party payer (more people!) NEVER makes anything cheaper. It only shifts costs from one group member to another – with the added administrative cost spread around to everyone. It INCREASES costs, but just hides them in the front end.

          Regarding my “utopia”, I have many patients with the “standard” chronic conditions (diabetes, hypertension, thyroid, etc.) and I can usually manage most of their issues for a reasonable cost including lab work and medications. Paying cash for labs typically gets me a much cheaper price than standard insurance reimbursements – often times 70-80% less. I charge at or near cost for my negotiated price. Most of my labs are $10/20/30. I recently had an uninsured patient pay $30 for our comprehensive panel (CBC, CMP, A1c, TSH) for which she had previously been paying $200+ for every 3-6 months for many years, so she certainly appreciates my little “utopia”.

          Re: medications. Yes, Rx can be absurdly expensive, but for there are usually generic alternatives for most conditions – especially if you shop around for best prices (mail-order, etc.).

          • sFord48

            RE: It only shifts costs from one group member to another

            Do you realize this is what insurance does…spreads risk? Some people pay more and don’t get as much.

            Every primary care doctor who wants to discuss costs or value of primary care, always uses diabetes as an example.

          • http://www.facebook.com/people/Ryan-Neuhofel/558505959 Ryan Neuhofel

            Yes, I realize it ONLY spreads risk. Hence my original statement. It INCREASES the cost but spreads it around. So, it only makes sense to use “insurance” when it’s absolutely necessary. Why would you want to decrease the “risk” of something you know is already going to happen? It’d be like “insuring” an oil change on a car or your lunch.

            What we have now in health “insurance” is called “managed care” (HMO, PPO, etc.) and it’s introduction (a la HMO Act of 1973) and adoption coincides directly with the skyrocketing price of “health care”. If you like for financial middlemen to get a cut of all your health care monies, power you to you – but I’d prefer to keep things simple. . . and cheaper.

            Why diabetes? Because it’s the most common and costly chronic disease in our country. We manage this “routine” disease and it’s terrible health effects everyday. If you’d like another example of a chronic “routine” disease, there is quite a long list to chose from. I have patients with most of them.

  • sFord48

    I have the option not to carry health insurance but it is not a wise option, so I am stuck with paying premiums. I feel sorry for those primary care physician that don’t like what’s happening in the current health care system but I don’t more money sucked out of my pocket.

  • http://www.facebook.com/bryan.rafferty.5 Bryan Rafferty

    Great job Ryan! Your ideas about bringing about that patient-doctor relationship panders to my thought of patients responsibility to their own care. This I see being achieved by 1) the patient being able to choose who they see; 2) patient education that shares every type of option and their side effects; and 3) forget health insurance…a monthly fee payed to the services to one doctor or group for year round consulting. I’ve only recently heard of some doctors doing number 3 just bc people can’t afford insurance, but they are willing to pay payments that won’t break the bank and help to keep the practice afloat. I don’t know if this is what you were trying to get at with the whole grassroots thing and all, but these are just some of my ideas. What do you mean by “disruptive innovation from the grassroots?

    Sincerely I would like to know more,
    Bryan

    • http://www.facebook.com/people/Ryan-Neuhofel/558505959 Ryan Neuhofel

      Thanks Bryan. I have opted out of the ‘managed care’ system and doing something loosely-termed Direct Primary Care. There have been an increasing number of docs around the country doing similar things, but I really just wanted to start with a clean slate and create something that made sense for me and my patients. My website has loads of info about our services, prices, etc.

      Indeed many people have chosen my practice because they “can’t afford” insurance. About 60-70% of my patients are fully uninsured, but I do have many ‘insured’ patients who choose to pay me directly because they appreciate a better level of service. My patients with HDHPs actually are very pleased with their arrangement.

  • http://www.7POH.com/ Natasha Deonarain, MD, MBA

    Dr. Ryan…thank you for speaking your truth! The great Sir William Osler said, “The first duties of the physician are to educate the masses on how not to take medicine.” He also said, “The greater the ignorance, the greater the dogma.” I think we have strayed so very far away from those wise words. I think we need to see a different paradigm, and begin with a new way of thinking. I think we need to understand that the Earth is not flat as those adamantly believed for so long, and come into a new way of thought and understanding that shows our medical system and its entire construct, including doctors and the way they have been forced to practice, are here to keep us sick and poor. If we start in a new paradigm, that of health first and walk on a new journey, we will find our way to health. That is why I am putting together a Health Conscious Movement. I would be honored if you would join and help. http://www.7poh.com and Facebook/TheHealthConsciousMovement.

  • John Vaughan

    Great article, Ryan. I too suffer from that dogged naiveté you mentioned. I have many times been the recipient of the puzzled looks and flippant answers. It seems as if I was reading my own autobiography. Excellent , enjoyable article.

    John Vaughan

    • http://www.facebook.com/people/Ryan-Neuhofel/558505959 Ryan Neuhofel

      Thanks John. It’s an affliction for which I’m afraid there is no cure!

      • http://twitter.com/zdoggmd ZDoggMD

        I was once told by an attending, “You speak, and then think. I want you to reverse that, or better yet, just think.” Winning!