Doctoring in the Age of ObamaCare
Endlessly entering data or calling for permission to prescribe or trying to avoid Medicare penalties—when should I see patients?
By Mark Sklar, MD : WSJ : September 11, 2014
It has been four years since the passage of the Affordable Care Act, so I thought it may be useful to provide the perspective of a physician providing daily medical care. I am an endocrinologist in Washington, D.C., and have been in solo private practice for 17 years after seven years at an academic institution. Since 1990, the practice of medicine has changed significantly, seldom for the better.
In the 1990s insurance companies developed managed-care plans that greatly increased their profits at the expense of the physician. With the Affordable Care Act, we are seeing new groups profiting from changes to the health-care system. Entrepreneurs and hospital executives are capitalizing on organizing physicians into groups called Accountable Care Organizations from which they will take a very substantial percentage of collected income. Now that physicians are being required to use electronic medical records, the companies that develop them are harvesting money from physicians' practices and from hospitals.
The push to use electronic medical records has had more than financial costs. Although it is convenient to have patient records accessible on the Internet, the data processing involved has been extremely time consuming—a sentiment echoed by most of my colleagues. To save time, I was advised by a consultant to enter data into the electronic record during the office visit. When I tried this I found that typing in the data was disruptive to the patient visit. My eyes were focused on the keyboard and the lack of direct contact kept patients from opening up and discussing their medical and personal problems. I soon returned to my old method of dictating notes and pasting a print-out of the dictation into the electronic record.
Yet to avoid future financial penalties from Medicare, I must demonstrate "meaningful use" of the electronic record. This involves documenting that I covered a checklist of items during the office visit, so I spend 90 minutes each day entering mostly meaningless data. This is time better spent calling patients to answer questions or keeping updated with the medical literature.
If electronic records ever allow physicians to obtain data from previous laboratory and imaging testing, it will improve costs and patient care. So far, however, the data in electronic records—like paper charts—can't be shared unless physicians work in the same health-care system.
My practice quickly adopted the new Medicare requirements for electronically prescribing medications. Yet patients often do not want their prescription sent electronically. They want a physical copy—either because they don't trust the Internet or because they don't need to fill the prescription immediately. If I don't electronically prescribe for a certain number of Medicare patients, I am penalized with a decrease in reimbursement that can rise to a maximum of 5%. Patients should have a choice in how their prescriptions are delivered, and physicians shouldn't be penalized for how the patients choose.
To prevent physicians from prescribing more costly medications and tests on patients, insurers are increasingly requiring physicians to obtain pre-authorizations. This involves calling a telephone number, often being rerouted several times and then waiting on hold for a representative. The process is demeaning and can take 30-45 minutes. Rather than having physicians pre-authorize expensive medications, the outrageous costs of many non-generic medications must be addressed. I understand that pharmaceutical companies need to make profits to cover investments in drug development. However, they should have some compassion for their customers.
To avoid Medicare penalties, I also must participate in the Physician Quality Reporting System program. Initially, this involved choosing three codes during the patient visit to reflect quality of care, such as blood pressure or blood-sugar control, and reporting them to Medicare. In 2015, the requirement will increase to nine codes.
Coming down the pike, but thankfully postponed from the October 2014 deadline, is something called ICD-10. This is a newer system that will contain about 70,000 medical diagnostic codes used for billing insurance. The present ICD-9 system has about 15,000 codes. The Physician Quality Reporting System and ICD-10 requirements are intended to benefit population research, but the effect is to turn physicians into adjuncts of the Census Bureau who spend time searching for codes—and to further decrease the amount of direct contact with patients.
The practice of medicine in the current environment is unsustainable. The multiple bureaucratic distractions in my day consume so much time that I have to give up what little personal time I have in the morning, evening and on weekends if I want to continue to provide excellent care during office hours.
If high-quality medical care is the goal, the bureaucracies need to be tamed. Our government and insurance companies understandably want to measure outcomes of health-care dollars spent. However, if the health-care system rewards data entry, that is what it will get—the quality of care seems an afterthought.
The patient should be the arbiter of the physician's quality of care. Contrary to what our government may believe, the average American has the intellectual capacity to judge. To give people more control of their medical choices, we should move away from third-party payment. It may be more prudent to offer the public a high-deductible insurance plan with a tax-deductible medical savings account that people could use until the insurance deductible is reached. Members of the public thus would be spending their own health-care dollars and have an incentive to shop around for better value. This would encourage competition among providers and ultimately lower health-care costs.
By contrast, the Affordable Care Act's plans for establishing "medical homes"—a team-based health-care delivery model—and accountability-care organizations will only add more bureaucracy and enrich the consultants and companies organizing these entities.
To improve quality, we need to unchain health-care providers from the bureaucracies that are strangling them fiscally and temporally. We can better control medical costs if we strengthen physicians' relationships with their patients rather than with their computers.
Dr. Sklar is an assistant professor of medicine at the Georgetown University Medical Center and at the George Washington University Medical Center.
Endlessly entering data or calling for permission to prescribe or trying to avoid Medicare penalties—when should I see patients?
By Mark Sklar, MD : WSJ : September 11, 2014
It has been four years since the passage of the Affordable Care Act, so I thought it may be useful to provide the perspective of a physician providing daily medical care. I am an endocrinologist in Washington, D.C., and have been in solo private practice for 17 years after seven years at an academic institution. Since 1990, the practice of medicine has changed significantly, seldom for the better.
In the 1990s insurance companies developed managed-care plans that greatly increased their profits at the expense of the physician. With the Affordable Care Act, we are seeing new groups profiting from changes to the health-care system. Entrepreneurs and hospital executives are capitalizing on organizing physicians into groups called Accountable Care Organizations from which they will take a very substantial percentage of collected income. Now that physicians are being required to use electronic medical records, the companies that develop them are harvesting money from physicians' practices and from hospitals.
The push to use electronic medical records has had more than financial costs. Although it is convenient to have patient records accessible on the Internet, the data processing involved has been extremely time consuming—a sentiment echoed by most of my colleagues. To save time, I was advised by a consultant to enter data into the electronic record during the office visit. When I tried this I found that typing in the data was disruptive to the patient visit. My eyes were focused on the keyboard and the lack of direct contact kept patients from opening up and discussing their medical and personal problems. I soon returned to my old method of dictating notes and pasting a print-out of the dictation into the electronic record.
Yet to avoid future financial penalties from Medicare, I must demonstrate "meaningful use" of the electronic record. This involves documenting that I covered a checklist of items during the office visit, so I spend 90 minutes each day entering mostly meaningless data. This is time better spent calling patients to answer questions or keeping updated with the medical literature.
If electronic records ever allow physicians to obtain data from previous laboratory and imaging testing, it will improve costs and patient care. So far, however, the data in electronic records—like paper charts—can't be shared unless physicians work in the same health-care system.
My practice quickly adopted the new Medicare requirements for electronically prescribing medications. Yet patients often do not want their prescription sent electronically. They want a physical copy—either because they don't trust the Internet or because they don't need to fill the prescription immediately. If I don't electronically prescribe for a certain number of Medicare patients, I am penalized with a decrease in reimbursement that can rise to a maximum of 5%. Patients should have a choice in how their prescriptions are delivered, and physicians shouldn't be penalized for how the patients choose.
To prevent physicians from prescribing more costly medications and tests on patients, insurers are increasingly requiring physicians to obtain pre-authorizations. This involves calling a telephone number, often being rerouted several times and then waiting on hold for a representative. The process is demeaning and can take 30-45 minutes. Rather than having physicians pre-authorize expensive medications, the outrageous costs of many non-generic medications must be addressed. I understand that pharmaceutical companies need to make profits to cover investments in drug development. However, they should have some compassion for their customers.
To avoid Medicare penalties, I also must participate in the Physician Quality Reporting System program. Initially, this involved choosing three codes during the patient visit to reflect quality of care, such as blood pressure or blood-sugar control, and reporting them to Medicare. In 2015, the requirement will increase to nine codes.
Coming down the pike, but thankfully postponed from the October 2014 deadline, is something called ICD-10. This is a newer system that will contain about 70,000 medical diagnostic codes used for billing insurance. The present ICD-9 system has about 15,000 codes. The Physician Quality Reporting System and ICD-10 requirements are intended to benefit population research, but the effect is to turn physicians into adjuncts of the Census Bureau who spend time searching for codes—and to further decrease the amount of direct contact with patients.
The practice of medicine in the current environment is unsustainable. The multiple bureaucratic distractions in my day consume so much time that I have to give up what little personal time I have in the morning, evening and on weekends if I want to continue to provide excellent care during office hours.
If high-quality medical care is the goal, the bureaucracies need to be tamed. Our government and insurance companies understandably want to measure outcomes of health-care dollars spent. However, if the health-care system rewards data entry, that is what it will get—the quality of care seems an afterthought.
The patient should be the arbiter of the physician's quality of care. Contrary to what our government may believe, the average American has the intellectual capacity to judge. To give people more control of their medical choices, we should move away from third-party payment. It may be more prudent to offer the public a high-deductible insurance plan with a tax-deductible medical savings account that people could use until the insurance deductible is reached. Members of the public thus would be spending their own health-care dollars and have an incentive to shop around for better value. This would encourage competition among providers and ultimately lower health-care costs.
By contrast, the Affordable Care Act's plans for establishing "medical homes"—a team-based health-care delivery model—and accountability-care organizations will only add more bureaucracy and enrich the consultants and companies organizing these entities.
To improve quality, we need to unchain health-care providers from the bureaucracies that are strangling them fiscally and temporally. We can better control medical costs if we strengthen physicians' relationships with their patients rather than with their computers.
Dr. Sklar is an assistant professor of medicine at the Georgetown University Medical Center and at the George Washington University Medical Center.
From the below it is obvious that there is a lot of frustration out there.......
Eyes Bloodshot, Doctors Vent Their Discontent
By Sandeep Jauhar : NY Times Essay : June 17, 2008
“I love being a doctor but I hate practicing medicine,” a friend, Saeed Siddiqui, told me recently. We were sitting in his office amid his many framed medical certificates and a poster of an illuminated lighthouse that read: “Success doesn’t come to you. You go to it.”
A doctor in his late 30s, he has been in practice for six years, mostly as a solo practitioner. But he told me he recently had decided to go into partnership with another cardiologist; his days, he said, will be “totally busy.”
“Your days aren’t busy enough already?” I asked.
The waiting room was packed. He had a full schedule of appointments, and after he was done with his office patients, he was going to round at two hospitals.
He smiled wanly. “Just look at my eyes.”
They were bloodshot.
“This whole week I haven’t slept more than about six hours a night.”
I asked when his work usually got done.
“It is never done,” he replied, shaking his head. “See this pile?”
He pointed to five large manila packages on a shelf above his desk. “These are reports I still have to finish.”
As a physician, I could empathize. I too often feel overwhelmed with paperwork. But my friend’s discontent seemed to run much deeper than that. Unfortunately, he is not alone. I have been hearing physician colleagues voice a level of dissatisfaction with medical practice that is alarming.
In a survey last year of nearly 2,400 physicians conducted by a physician recruiting firm, locumtenens.com, 3 percent said they were not frustrated by nonclinical aspects of medicine. The level of frustration has increased with nearly every survey.
“It will take real structural change in the work environment for physician satisfaction to improve,” Dr. Mark Linzer, an internist at the University of Wisconsin who has done extensive research on physician unhappiness, told me. “Fortunately, the data show that physicians are willing to put up with a lot before giving up.”
Not long ago, fed up with what he perceived as a loss of professional autonomy, Dr. Bhupinder Singh, 42, a general internist in New York, sold his practice and went to work part time at a hospital in Queens.
“I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.”
When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.
“But managed care is like a magnet attached to you,” he said.
He continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ”
Recently, he confessed, he has been thinking about quitting medicine altogether and opening a convenience store. “Ninety percent of doctors I know are fed up with medicine,” he said.
And it is not just managed care. Stories of patients armed with medical knowledge gleaned from the Internet demanding antibiotics for viral illnesses or M.R.I. scans for routine symptoms are rife in doctors’ lounges. Malpractice worries also remain at the forefront of many physicians’ minds, compounded by increasing liability premiums that have forced many into early retirement.
In surveys, increasing numbers of doctors attest to diminishing enthusiasm for medicine and say they would discourage a friend or family member from going into the profession.
The dissatisfaction would probably not have reached such a fever pitch if reimbursement had kept pace with doctors’ expectations. But it has not.
Doctors are working harder and faster to maintain income, even as staff salaries and costs of living continue to increase. Some have resorted to selling herbs and vitamins retail out of their offices to make up for decreasing revenue. Others are limiting their practices just to patients who can pay out of pocket.
There are serious consequences to this discontent, the most worrisome of which is that it is difficult for doctors who are so unhappy to provide good care.
Another is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners.
Last year, residency programs in family practice took only 1,096 graduating medical students, the fewest in the last two decades. The number increased just slightly this year. Students who do choose internal medicine increasingly are forgoing primary care for subspecialty practices like cardiology and gastroenterology.
“For me it’s an endless amount of work that I can never get through to do it properly,” said Dr. Jeffrey Freilich, 38, a primary-care physician on Long Island. “I’m a bit compulsive. As an internist, I have to worry about working up so many conditions — anemia, thyroid problems and so forth. There is no time to do it all in a day.
“On top of all that, there are all the colonoscopies and mammograms you have to arrange, and all the time on the phone getting preauthorizations. Then you have to track the patient down. And none of it is reimbursed.”
Many primary-care physicians have stopped seeing their patients when they are hospitalized, relying instead on hospitalists devoted to inpatient care. Internists have told me that it is prohibitively inefficient to drive to a hospital, find parking, walk to the wards, examine a patient, check laboratory tests and vital signs, talk to a nurse and write orders and a note — for just a handful of cases. They cannot afford to leave their offices long enough to do it.
The upshot is that the doctor who knows a patient best is often uninvolved in her care when she is hospitalized. This contributes to the poor coordination and wanton consultation that is so common in hospitals today.
“Years ago you had one or two doctors,” a hospitalized patient told me recently. “Now you’ve got so many people coming in it’s hard to know who’s who.”
A 10.6 percent cut in Medicare payments to physicians is scheduled to take effect on July 1. Further cuts are planned in coming years. Many doctors have told lawmakers that if the cuts go through, they will stop seeing Medicare patients. But reimbursement cuts are only a small part of doctors’ woes today.
“I was naïve,” Saeed Siddiqui said. “When I was a resident I thought it was enough to take good care of patients. But the real world is totally different.”
The collapse of primary care
By Roger A. Rosenblatt, MD : Seattle Times : March 29, 2006
Health care in the United States is like a house riddled with termites. On the outside, everything looks fine: Gleaming hospital towers punctuate the skyline; MRI machines produce stunning images; and surgeons use robots to work miracles. But underneath the surface, the foundation is starting to sag: Tens of millions of people have no health insurance, emergency rooms are overwhelmed by patients who don't have regular physicians, and the cost of medical care is rising into the stratosphere.
One of the reasons for the rot at the core is the impending collapse of primary care, the family doctors and other health-care professionals who are the foundation of the health-care system. Just as your house cannot stand without its supporting beams, neither can the health-care system function without doctors and other clinicians who are experts in primary care. They work to prevent illness before it occurs; manage people with complex chronic diseases; care for pregnant women and their babies; and attend to the mental-health and substance-abuse problems that produce so much illness and social disruption.
Why is the primary-health-care system unraveling? The main reason is that new physicians are not choosing to pursue careers as family physicians and general internists, the two physician groups that provide primary care for adults. The number of medical students entering family medicine residencies — the graduate training programs that take medical students and turn them into licensed physicians — has declined 52 percent in seven years.
The reasons for this seismic shift in medical student career choice are not hard to find: Reimbursement rates for primary care have declined, student-loan debts have skyrocketed, and the complexity of caring for an aging population has become more and more challenging.
The situation has been made worse by the federal government's decision to drastically cut funding for training family physicians (a program called Title VII) at the same time the need for these physicians has increased.
[The remainder of his article pertains to community health centers and has been omitted]
Where Have All the Doctors Gone?
By Patricia Barry : AARP Bulletin print edition : September 2, 2008
Having health insurance doesn’t guarantee access to physicians. Judy Johnson, for example, says she had “insurance up the ying yang”—primary employer coverage, secondary Medicare coverage and medigap supplementary insurance—and still couldn’t get in to see a doctor last year after noticing a mole on her arm “doing weird things.” It turned out to be melanoma, a potentially deadly cancer. Having just moved from the San Francisco area to 50 miles north of Sacramento, Johnson, 68, didn’t have a new primary care physician who could make a referral. So it took months to see a dermatologist—typically those she called said they couldn’t schedule an appointment for three or four months. “I can’t tell you how many times I was in tears, just over trying to coordinate insurance, doctors and care,” she says. It was seven months before she had surgery to remove lymph nodes. Now the melanoma has spread to her lungs. “If I’d gotten in to see somebody sooner, like right away, it might not have spread so far,” she says. “But it’s turned into a big mess.”
Donna and Larry Bry spent two years trying to find a primary care physician who would take them as Medicare patients in Salem, Ore. Photo by Jonathan Sprague/Redux
When Donna and Larry Bry moved from Oregon’s coast to its capital city, Salem, in May 2006, they started looking for a new primary care doctor. It took two years to find one.
At first it didn’t matter much. Though beyond retirement age, the Brys were healthy, and when they needed prescriptions filled every three months they drove back to their old home on the coast—a round trip of about 160 miles. But one day the side of Larry’s face swelled up so badly that it closed his eye, and he went to the emergency room. He had a severe case of shingles.
He needed a neurologist. “But nobody would see him unless we had a primary care doctor, and we couldn’t find one,” Donna says. “We pounded the phones day after day, going through the whole list [of primary care doctors] in Salem. But everyone who accepted new patients would not accept people on Medicare.”
The Brys’ experience is not an isolated case. At least 56 million Americans, almost one in five of the population, are now “medically disenfranchised”—having inadequate access to primary care physicians because of shortages in their area—according to “Access Denied,” a county-by-county study by the National Association of Community Health Centers and the Robert Graham Center, a research group that focuses on primary care.
Among Medicare beneficiaries, about 3 percent—more than 1.3 million people—have difficulty finding a new primary care physician, a government survey found last year.
As the population ages, with the first wave of the nation’s 78 million boomers due to turn 65 in 2011, experts say the shortage of primary care physicians—those trained in general internal, family or pediatric medicine—is already a crisis. It’s a factor that’s often overlooked in the growing demand for universal health care. “Ensuring everyone has health insurance without ensuring them a regular source of primary care,” the “Access Denied” report warns, “is like providing currency without a marketplace.”
Most people living in areas where shortages are most acute actually have insurance, the report found. So did most of the AARP Bulletin readers who shared their problems trying to find physicians. Californian Judy Johnson, for example, had insurance but couldn’t get in to see a doctor until she lucked into a referral. [See sidebar on Johnson’s experience, page 14.]
So where have all the doctors gone? “The pickle we’re in is that [primary care doctors] of my generation are stopping practice early and the young people are not choosing it as a profession,” says Jeffrey Harris, M.D., president of the American College of Physicians, which represents 126,000 internists. “To say that primary care is collapsing is not hyperbole.”
The reasons why primary care doctors are retiring early and new doctors are not replacing them are pretty much the same, Harris and other physicians say. Their earnings on average are half or a third of those of doctors in many specialties, yet their workdays are longer and their overhead higher. Hours spent on paperwork and phone calls for prior authorizations demanded by insurance companies reduce the time spent with individual patients—so does the pressure to take on as many patients as possible to stay in business. New medical school graduates realize this: The number going into family medicine declined by more than half from 1997 to 2005. By 2006 only 13 percent of first-year residents in internal medicine said they intended to pursue it in general practice.
The experience of one small-town primary care doctor sums up what is happening. Fred Ralston Jr., M.D., is an internist in Fayetteville, Tenn., where his family settled 120 years ago. The practice has seven physicians, a nurse practitioner and more than 30 others on staff. He personally has 2,000 patients, sees 20 a day in his office and others at the hospital and nursing homes. His world is totally different now from when he started practice in the 1980s, he says. “There were plenty of primary care physicians, and we had time to see and get good relationships with patients,” Ralston says. There was little paperwork, and the practice’s overhead was “less than 40 percent of every dollar we took in.” Now, he says, it’s around 65 percent, of which at least 40 percent is spent dealing with insurance companies. “It’s a very large part of our expense.”
Despite his own job satisfaction, Ralston doesn’t blame young doctors for not going into primary care when they can choose other specialties with defined hours, higher salaries and less hassle, especially when they have huge debts from school and young families. But he can see the effects. “Every neighborhood in the country is one doctor away from a crisis,” he says. “If I go away and my 2,000 patients are let loose on the market, there are not enough doctors to absorb them.”
Because fees are fixed by Medicare and insurers, the only way primary care doctors can generate revenue is to take on more patients, which means spending less time with each—often no more than 15 minutes. “The commonest complaint you hear from patients is: ‘I don’t have enough time with the doctor,’ ” says the ACP’s Harris. “They’re right. You can’t take good care of people with chronic conditions in 15 minutes.”
A recent ACP study compared the U.S. health system with those of 12 other countries and analyzed why the latter had better medical outcomes for far less funding. “The take-away message,” says Harris, “is that systems with primary care as a cornerstone are less expensive and have better quality.” The American system needs new strategies, he says, starting with medical school training, which currently favors overspecialization. Among many proposals for improving the situation is forgiveness of medical school debts for graduates who go into primary care, restructuring the way those doctors are compensated and, above all, establishing “patient-centered medical homes.”
The point of a medical home is for patients to have an ongoing relationship with a personal physician who leads a team that coordinates care. The approach would allow more time for patients, especially those with multiple chronic conditions. The doctor’s compensation would be tied to meeting certain standards and bundled into a “care coordination” fee for each patient. Patients would be able to ask questions by e-mail or phone and schedule appointments on short notice.
That at least is the ideal. As yet, only two practices—in Maine and Maryland—meet all the standards for a medical home set by the National Committee for Quality Assurance. Medicare, Medicaid and some insurers are already experimenting with pilot projects. Some members of Congress are working on legislation to make medical homes more feasible.
In the meantime, though, the access situation is likely to become worse before it gets better. Donna and Larry Bry finally found primary care 30 miles away, from a husband and wife newly graduated from medical school, on a tip from another doctor’s receptionist. Judy Johnson found hers through her grandson’s new basketball coach. His family had just moved to the area, and his wife was a rare find—a primary care doctor looking for new patients.
Crisis of Care on the Front Line of Health
By Jane E. Brody : NY Times Article : September 30, 2008
Does your doctor spend time talking to you? Do you see your doctor within 20 minutes of your appointment time? Are you getting the guidance you need to cope with a continuing health problem or multiple overlapping problems? Do you even have a personal physician who monitors your health and treats you promptly with skill and compassion?
A “no” answer to any of these questions — even to all of them — would not be surprising. Finding doctors who know their patients well and who deliver informed medical care with efficiency and empathy has become quite a challenge in America.
There is a crisis in medicine today, and it will not be fixed by any candidate’s proposal to provide health insurance for the 45 million Americans now without it. In fact, an increase in insured Americans could make it worse.
The crisis is a diminishing supply of primary care physicians, the doctors on the firing line — family physicians, internists, pediatricians, gerontologists and others — who practice the art and the science of medicine and who seek to put patients at least on a par with their pocketbooks.
According to a study published this month in The Journal of the American Medical Association, the number of medical students choosing to train in internal medicine is down, and young physicians are leaving the field. Other primary care specialties, including family medicine and gerontology, have also reported drops.
Primary care doctors spend far more time talking to patients and helping them avert health crises or cope with ailments that are chronic and incurable than they spend performing tests and procedures.
They are the doctors who ask pertinent questions, about health and also about life circumstances, and who listen carefully to how patients answer. They are the doctors who know their patients, and often the patients’ families, and the circumstances and beliefs that can make health problems worse or impede effective treatment.
The problem is that in this era of managed care and reimbursements dictated by Medicare and other insurers, doctors don’t get much compensation for talking to patients. They get paid primarily for procedures, from blood tests to surgery, and for the number of patients they see.
Most are burdened with paperwork and hours spent negotiating treatment options with insurers. And the payments they receive for services have not increased as the costs of running a modern medical practice have risen. To make ends meet and earn a reasonable income of, say, $150,000 a year, many primary care doctors have to squeeze more and more patients into the workday.
“If you have only six to eight minutes per patient, which is the average under managed care, you’re forced to concentrate on the acute problem and ignore all the rest,” said Dr. Byron M. Thomashow, medical director of the Center for Chest Diseases at New York-Presbyterian Columbia Medical Center.
Yet, he said in an interview, in a study of more than 3,000 patients with chronic obstructive pulmonary disease, 50 to 60 percent had one or more other illnesses, and 20 percent had more than 11 other problems that warranted medical attention.
“There just isn’t the time to address them all,” he said.
Dr. Alan J. Stein, an infectious disease specialist in private practice in Brooklyn who treats many patients with H.I.V., described his practice as “heavily cognitive.”
“I spend a lot of time talking to patients — listening to them, examining them, interpreting tests and figuring out what’s wrong,” he said in an interview. “I don’t do procedures in the office. Over the last 10 or 15 years, the income of procedure-based physicians like cardiologists has increased significantly, whereas for those in primary care it has remained the same.”
Dr. Michael Stewart, chairman of the department of otorhinolaryngology at New York-Presbyterian Weill Cornell Medical Center, said in an interview that the challenge today was that “everything is going up except reimbursement. The tendency is to see more patients in a given amount of time, and so less time is spent with each patient.”
As a result, many who became doctors because they are genuinely interested in helping people get well and stay well or live a good life despite a continuing illness are increasingly disillusioned. Like Dr. Thomashow, a growing number of independent physicians are finding that the only way they can practice effectively is to not accept insurance and to ask patients to pay out of pocket.
Dr. Allen Bowling, a neurologist affiliated with the Rocky Mountain Multiple Sclerosis Center in Englewood, Colo., decided last year to convert his “busy, high overhead, insurance-based M.S. practice to one that has lower overhead, is moderately busy, and does not accept any private or government insurance.” He did that, he wrote in Neurology Today in June, to give his patients “high-quality, personalized and moderately priced care with easy access to the neurologist.”
He is passionate about caring for multiple sclerosis patients, he said, but to continue practicing the kind of medicine they deserve, he had to change how he was reimbursed.
“Good doctors do drop out of managed care, and in the future I might have to drop out as well,” Dr. Stewart said. He acknowledged that specialists like him have an advantage.
“The amount of time I spend with patients is not such an issue,” he said. “But this is a big problem for primary care specialties where patients need a lot of time.”
Even some salaried academic physicians like Dr. Douglas A. Drossman, who runs a respected clinic where patients are treated regardless of ability to pay, often have to scramble for grants from foundations and industry to support their work with patients.
Dr. Drossman, co-director of the Center for Functional Gastrointestinal and Motility Disorders at the University of North Carolina, said the salaries he and his colleagues receive do not cover the program’s costs. The program treats patients with life-disrupting chronic conditions like irritable bowel syndrome, many of them referred by other diagnostic centers like the Mayo Clinic.
“Many patients who come to us have been to countless doctors and told that there’s nothing organically wrong with them, it’s all in their heads and they just have to live with it,” Dr. Drossman said. “These patients wonder whether something has been missed. They’ve had all the tests. There’s no need to do more. But it takes time to help patients understand theirs is a real problem and to learn how to deal with it.”
Dr. Karen E. Hauer of the University of California, San Francisco, who directed the study of medical students, said in an interview that students were “turned off by the hassles in the practice environment — the paperwork, insurance issues, pace of work and expectations to get the work done quickly without having adequate time to spend with patients.”
This is a particular problem for doctors who treat the growing older population. Trends suggest there will not be nearly enough doctors for these patients, Dr. Hauer said.
Whatever the future of health care may hold for Americans, Dr. Thomashow said, “We need to go forward with something that keeps the humanity in medicine.”
