A guest column by the American College of Physicians, exclusive to KevinMD.
Although I work for the American College of Physicians, I’m writing this as a general internist who has practiced both primary care and hospital-based medicine for over 25 years.
Hopefully by now, you are aware of Better is Possible: The American College of Physicians’ Vision for the U.S. Health Care System published in January. As a point of disclosure, I had no direct role in developing this vision statement. However, as a practicing physician, I can’t help but see it as a major step toward the medical profession reclaiming the direction of health care in our country. Let me explain.
When I began my career, medicine was a markedly different world. Physicians occupied a much more central role in how health care was provided. Fee-for-service was the predominant payment model, and insurers, health care organizations, and businesses held far less power and control over how medicine was practiced. However, the rapid expansion of our country’s extraordinarily unusual health care infrastructure in which massive amounts of money flow in a system driven largely by market forces, the stage was set for development of the health care system we have today. And frankly, at that time, I couldn’t have imagined that we would ultimately end up with the health care system we have today.
Unfortunately, organized medicine did not respond to the challenges posed by these external forces in a unified, collective manner. The independent nature of physicians has always encouraged internal fragmentation within the medical community, and segments of the physician workforce responded to differing incentives, ranging from those focused on holding true to the traditional precepts of medicine to those more highly motivated by preserving income and control. Doctors have seemingly never been able to speak with one voice, with the result being a remarkable diminution in physicians’ ability to guide the systems that provide care, a role subsequently taken over by others. The consequence has been a system driven far more by competitive advantage and profitability than by core medical values based on patient and societal wellbeing.
Those of us who have been in medicine long enough have been whipsawed through change after change in the health care system over the years – a shift from fee-for-service to managed care to accountable care organizations; mergers and demergers; vertical and horizontal integration; the rapid growth of lucrative for-profit medical businesses; movement away from primary care to a focus on high reimbursement specialty “service lines,” the outsized role of the pharmaceutical industry, and many others that are certainly not driven by the desire to provide optimal patient care.
And we’ve also experienced the profound implications these systemic changes have had on patients. Despite the amazing strides that have occurred in the science of medicine and the ability to effectively prevent, diagnose, and treat disease, the current system that could provide this incredible care is simply too complex, too difficult to navigate for individual patients, inaccessible to many, and often glaringly ineffective in providing the care that is needed.
And as clinicians, almost all of us have had to deal with the practical implications of this system in caring for patients. Being in a generalist and primary care field, these challenges are particularly difficult. Over the years, I’ve consistently been compelled to actively “workaround” the system on behalf of my patients. This has included things such as seeing uninsured patients without charging them, and at times even “sneaking” them onto my schedule so they won’t be billed. I’ve spent hours and hours attempting to manipulate the system to get my patients the care they need when they either don’t have access to it or cannot afford it. And yes, despite the obvious ethical and boundary issues involved, I’ve even paid for medications for some of my patients who could not afford them whose health and wellbeing would be in jeopardy without them. And I’ve experienced the eternal heartbreak of simply not being able to provide the care I know would help my patients live better lives solely because of systemic obstacles.
And this is not to mention the associated administrative burden that is an integral part of our current health care system – the extraordinary amount of time spent on documentation, pre-approvals, “peer-to-peer” discussions, and a wide variety of activities that are only marginally related to actually caring for patients, if at all.
A just, fair, equitable, and effective health care system simply doesn’t treat patients the way ours does, nor does it make physicians work this way in attempting to provide care for them.
The New Vision painstakingly documents the data underlying these issues we all encounter on a daily basis, and draws the only reasonable and logical conclusion from this evidence – that our current system is irrevocably broken, and that if we are to return to our prime role as caregivers that the system needs to be truly fixed. And perhaps most important, that patients and physicians need to be central to this process.
It is almost certain that many will not agree with the potential solutions for how to solve these structural and functional problems put forth in the New Vision, and that is both expected and welcome. A spirited debate around issues of such great importance is a sign of both a healthy profession and society.
However, of greater significance is that the New Vision represents a clear and definitive starting point for physicians to collectively recapture the conversation around health care, and more importantly, reclaim our central role in influencing the trajectory of how medicine is practiced in our country – if we choose to take the challenge. And as a physician who has struggled, along with my patients, to achieve even basic health outcomes in our current system, I believe it is an opportunity we need to heartily embrace.
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