The micro level of health reform cannot be ignored

Much of what passes for debate on health care during this election year is focused on the macro side, on big issues like how do we cover the uninsured or restructure Medicare and Medicaid financing.  But for all of the talk about vouchers and block grants and insurance mandates, the candidates are missing the micro issues that really matter most to doctors and their patients, which is how health care policy directly affects the quality of the patient-physician encounter.

Talk to physicians around the country, as I regularly do, and these are some of the issues that have them most concerned:

1. Will anyone do anything about the oppressive burden of paperwork and red tape?
2. Will the candidates’ “macro” proposals for reforming healthcare and entitlements result in more or less paperwork and red tape?
3. I already don’t have enough time to spend with patients but now I am expected to counsel them on preventive care, lifestyle choices, and the effectiveness of different treatments?   How is this possible?
4. Electronic health records, great concept, but they don’t really streamline the process as advertised, if anything, they just make things more difficult, and besides, they still don’t communicate with other systems.
5. Everyone wants to measure me, but the measures don’t agree with other, they measure the wrong things and they are difficult to report on.   And who is measuring the value and effectiveness of the measures themselves?
6. Okay, I am supposed to practice cost conscious care, but who is going to stop a lawyer from suing me if I don’t give a patient the test they asked for?
7. Why is my cognitive care paid so little while procedures and drugs are paid exorbitant rates?
8. Payers and government keep imposing more penalties, for not e-prescribing, for not converting to ICD-10, for not meaningfully using my electronic health record, for not complying with their pay for performance schemes.  By the time they get done fining me for noncompliance, I will have had to shut my office. Then who will take care of my patients?
9. And who has the time to keep track of all of these mandates, incentives, rules, and penalties?  I would have to hire a full-time person keep on top of everything. Who is going to pay for that?
10. So I am supposed to transform my practice?  Well, we all want to do our part, but who is going to pay for that?  Besides, my patients seem to think my practice is just fine as it is

Now, I don’t really expect Obama and Romney to come out with plans to address these micro health policies.  But it is reasonable to hold their macro proposals to a standard of whether they will make all of these aggravations and intrusions better or worse.  And at some point, policymakers–no matter their political leanings and plans to reform healthcare at the macro level, need to pay attention to what is happening at the micro patient-doctor encounter level.  After all, the boldest of big ideas won’t make healthcare better if it makes it harder for physicians to give their patients the care they need.

Physician advocacy organizations also need to pay attention to the micro issues.  ACP prides itself on taking on the big issues like controlling health care costs and allocating health care resources rationally.   But the College puts at least as much effort into the micro issues, from objecting to the latest EHR mandates to offering alternatives to ICD 10 coding to advocating for higher payments.

The goal must be to fashion public policies that improve care at the macro level — universal access to coverage, spending health care dollars more wisely, and improving healthcare delivery systems — while also removing barriers at the micro level that intrude on the patient-doctor relationship.  Both are equally important.

Bob Doherty is Senior Vice President of Governmental Affairs and Public Policy, American College of Physicians and blogs at The ACP Advocate Blog.

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  • StaySharp

    This is a feature, not a bug.

    Many of these regulations are designed to aggregate healthcare providers and move our healthcare system away from a practice-centric method of providing care and more toward an institutionalized HC system. Why do you think there’s the big push now toward ACOs? They believe that larger institutions provide better coordination…and they might be right, but that’s why they push. They want you to have administration.

  • StephenModesto

    Thank you for your post. It is a bit reasuring to note your `position’ in the super/infrastructure of the of the health care `business’. It is also reasssuring to see that someone is openly acknowledging the issues you describe, which are self-evident to all those who work in the business at all levels of that hierarchial structure.

  • Laurie Morgan

    Pretty comprehensive — if discouraging — list.

  • Christine A. Sinsky

    The granular issues discussed here are those that many of us have been working to address through primary care redesign in general, and through an American Board of Internal Medicine Foundation sponsored project, “In Search of Joy in Practice,” in particular. Primary care physicians are caught in a growing number of administrative and regulatory requirements, which coupled with health information technology that often makes doing the same work harder and more time consuming, has sapped much of professional satisfaction.

    After I presented a talk on practice redesign recently a family physician told me that in her organization she can no longer ask her nurse to do an ear wash. Instead she must go to her computer, fire it up, log in, and create a computerized order for the ear wash, a series of steps that takes minutes rather than seconds. Multiply this across all of the acts doctors do every day and this misuse of physician resources represents a colossal waste, all the more so in that it is driving physicians away from primary care and other non-procedural specialties. More waste may be on the horizon with Meaningful Use Stage 2, which prohibits receptionist staff from keyboarding in orders for tests such as lipid profiles and mammograms, creating more clerical work for physicians and nurses.

    I wonder when we will come to our senses about this sheer madness.

  • ljslossmd

    To amend an old folk saying, “many a micro makes a macro.”

    I agree with all of Doherty’s points and could make a few additions and amendments, but the big picture is that the sum of the myriad little miseries facing medical practice is going to be a “tipping point event” that will result in the mass departure of intelligent, independent and motivated individuals from the study and practice of medicine. Facing such persons with the options of debt, years of indentured servitude, noncompetitive future income and opportunity, burdensome administrative oversight and regimentation, great responsibility and potential personal liability without control of their own actions (and on and on) would drive any such person to look elsewhere than a career in medicine for self fulfillment and the opportunity to contribute to society. We have a shortage of physicians now and a growing and aging population with high expectations for access and quality which will be impossible to meet. We are developing a healthcare system that will process depersonalized consumer units by the actions of regimented and programmed “providers” who will be serving the masters of their organization. All of the structure of medical planning and the grossly wasteful third-party payment system (eagerly awaiting the influx of the unwilling) are pushing medicine into a punitive mediocritization that serves neither the populace nor those who would be healers had they not been so severely constrained and trivialized by the downward evolution of our profession.

    The record of government and of the professional societies and organizations in providing meaningful representation and effective action is that of disregard, impotence and utter failure. For every piddling amelioration there have been avalanches of rules, constraints, threats and inexplicable (downward) adjustments in remuneration, operational independence and the value accorded to all that is personal, individual, humane and honorable in a profession once characterized by high moral purpose but now sunk to compliance, obedience and grubbing for scraps.

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