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.