A physician responds to Sarah Kliff

A response to Unpaid, stressed, and confused: Patients are the health care system’s free labor.

Dear Sarah,

I am genuinely sorry about your chronic foot injury.  Thank you for your insightful article and feedback.  You are correct the system is fragmented and places “considerable burden” on patients to “coordinate their own care.”  You (the patient) and me (a physician) are now in the same boat, headed the same direction with the same goal (better health care system), however, we are still not rowing in sync.  We are on the same side.  We need to work together.  You are part of the media and a frustrated patient; I am just another run-of-the-mill discouraged physician, who cannot get my message across to the masses.

I love your description of patient-centered care; I have the same dream.  For 15 years, I have been a pediatrician in private practice in the small town where I was born and raised.  I love my patients like they are my own children.  Having a clinic with a nurse, lactation consultant, behavioral therapist, and social worker would allow me to provide seamless care coordination to my young patients no matter their station in life.

Believing all children deserve health care, I am one of the few pediatricians who still accepts Medicaid patients.  I am paid a very small amount per visit.  If I hire a team to help with care coordination, I would have to divide the same small amount of money between five people.  Once MACRA gets going, I will receive $3 less for each encounter because I am in solo practice, which the Center for Medicare and Medicaid Services (CMS) considers not “efficient” enough for their way of doing business.

You could say I am a physician obsessed with providing the best possible outcomes for my patients while reducing the footprint on their daily lives.  I may not be “efficient” enough for CMS, but I am very effective at what I do.  In 15 years, I have yet to admit one patient for an asthma exacerbation or dehydration from vomiting.  I see sick patients the same day, and my families rarely go to the ER except for true emergencies.  It is astounding to me that my small clinic is not considered a valuable commodity in the health care world today.

You see value-based care is a matter of perspective.  My small clinic does not see adequate volume for the insurance companies to determine if we are cost effective.  An insurance company executive would think I spend too much time with my patients, know them far too well, and ultimately do not bring in enough profit for their CEO to pass on to stockholders.  Sad, but true.

Are insurance metrics valuable?  As you said, none of the current quality metrics take patient work into account. Guess what? They do not take physician’s work into account either.  Immunization rates are important to track in pediatrics.  A recent study in the Journal of Pediatrics determined physician intervention and additional communication did not change parental vaccine refusal rates.  So why are immunizations rates tracked as a measure for value-based reimbursement if they cannot be impacted by physician ability, time, or effort?

But I digress.  My reason for responding to you is this:  I acknowledge patients are forced to work hard to navigate the system.  As physicians, we want to make patients’ lives easier, better, and healthier.  Our obstacle to providing superior quality care and transparency is that it requires physician-patient interaction, something not considered valuable to those controlling the health care system.  Health care is no longer based in human interaction; it is now based on business transactions and statistics.  Our relationship as physician and patient is no longer considered worthwhile to a larger system obsessed with numbers.

The only point upon which I respectfully disagree is patients are not exactly the “health care system’s free labor”; more accurately, they are “free labor for the business of health care.”  Who benefits most by transferring the “health care footprint” to patients?  Physicians do not benefit in any way, shape, or form.  Creating barriers for patients to obtain medications, services, or care coordination increases our workload as well as yours.  Health care business benefits most from transferring the work to patients because they can generate considerably more income.

If you were a patient of mine, obtaining your MRI report would be simple.  Call us on the phone and request a copy.  We have two employees in the front.  They would make a copy, and you could have stopped by on your lunch hour to pick it up for your orthopedics appointment.  Of course, our office still has paper charts making things much easier and more efficient for you.

My closing thought is this: Many years ago, primary care physicians dictated a brief one-page synopsis letter containing all of your pertinent information and mailed it to your specialist prior to your appointment in order to better facilitate your care.  That meant no work on your part other than showing up to see the specialist.

In my humble opinion, that type of communication provides tremendous value.  Paying more to a physician who provides services that benefit patients directly is a metric worth tracking.  If physician and patient can work together by rowing in sync on the same boat, maybe we could get those in control of the health care system on board with us after all.  Medicine is not a one-way road.  You are spot on about that.


Niran S. Al-Agba, MD

Niran S. Al-Agba is a pediatrician who blogs at MommyDoc.

Image credit: Shutterstock.com

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