American Healthcare Blog Archives - Page 3 of 3

Why Can’t You Talk to Your Doctor?

So is your usual experience in going to the doctor’s office characterized by calling for an appointment, and, if you’re lucky, waiting for several days to be seen? And when you finally get there, you feel that you’re not given the time to address your concerns? Have you even written down a list of your problems, to make your visit more efficient, and your doctor simply tells you that he can only deal with one problem on the list at a time, telling you that you’ll have to make other appointments for each of those other concerns? Have you left, feeling frustrated and ignored? Wondering why the physician would treat you like that? After all, didn’t he go into medicine to help people? Has your anger simmered as you walk out the door?

You may remember some TV physician lending a sympathetic ear to his patients. Or hearing a story about a specialist who calls their patients at home at night, just to see how they are doing. Why isn’t your physician like that? How did the present state of physician care devolve into what is happening today?

To find an answer one need look no further than recent banking regulations which made it much more difficult for new medical practitioners to get loans to start their own practices. Coming out of medical school, saddled with educational debt that, in many cases, exceeds 250,000 to 500,000 dollars, most new providers opt to go to work for hospitals or large medical clinics who can subsidize those loans and start-up costs. And in many cases it has resulted in physician schedules being managed by administrators with no medical training, who feel that the only way to recoup some of their expenses is to ensure that each provider sees patients every ten minutes; not enough time to address complex issues.

As a result, more and more patients are being referred to specialists for evaluation. More and more are referred to urgent care centers or to emergency rooms for treatment. And costs continue to escalate while the ultimate quality of care suffers. This has resulted in physician costs now representing 20% of the total cost of care. However only a small percentage of that is actually going to the primary care physician who ends up feeling as if he is providing medical care on an assembly line.

In Scandinavian countries like Sweden and Norway, where there is a single payer system, to avoid these pitfalls, physicians are given a salary rather than relying on their productivity to determine their income. And education costs to train a physician are not as exorbitant as they are in this country. But, on the flip side, there is no incentive for them to work long hours and care gets even more fragmented, with each provider only responsible for one aspect of each patient’s care.

So while our present system is expensive, and clearly not ideal, there remains no single solution to the current quandary. The employee who can best schedule physicians’ visits is the physician himself. Unfortunately few of them have been trained in how to do this efficiently or with an appreciation for the fiscal realities of supporting his/her practice. And many of the commercial insurers choose not to look at the overall cost of providing care to a patient but rather at the expense of each individual provider’s charges. And, in addition, will provide periodic audits of providers to find out if their visits are medically necessary, a time consuming endeavor for a physician already over-taxed trying to provide that care.

What’s more, insurers have come to the realization that, in the greater scheme of things, the costs generated by individual health providers is not the single biggest driver of the cost of healthcare at this point. Instead, when looked at overall, it is the type of patients seen, whether elderly patients, or those that are chronically ill, that are driving healthcare costs. And these expenses are derived from the expenses inherent in hospital care and home care provided to them. And in the expensive testing and treatment options that now exist. So while managers still try to increase revenue from their employed physician practices by increasing the number of visits per hour, insurers are looking elsewhere to try to limit the rising costs of health care.

Next time we will look at hospital care and explore why the lengths of your hospital stays are shrinking, leaving you feeling prematurely abandoned by the system. Questioning how you could possibly be ready to go home after that surgery or hospital stay.

Where Does the Money Go?

If the cost of health care in the US is so much more expensive than it is in other countries, where does all the money go? It’s tempting to blame the doctors. But they represent only about twenty percent of the expenditures. And it is only recently that it has gotten this high. Hospitals account for about 32 percent of the monies spent, and drugs account for another ten percent. Which leaves nearly a third of the expenditures unaccounted for. These are usually attributed to nursing homes, rehabilitation and home health care services as well as wide spread, expensive testing and procedures.

Did you know that only five percent of the population account for half of all health care expenditures per year? And that approximately half of the population account for less than 3 percent? It has been estimated that people consume 80% of their health care dollars in the last year of their lives. Most industrialized nations have come to that conclusion and limit their health care spending by simply limiting the health care choices for their populations once they achieve a certain age, like retirement age.

Clearly this country has little appetite for limiting access to care simply based on a person’s age. So Congress and the insurance industry have looked to find other, more palatable ways of limiting their financial exposure.

This began in the 1990’s with the advent of HMO’s or health maintenance organizations. Since most of these insurance products targeted a younger age demographic, most of the costs associated with their members’ care were due to high cost testing and physician fees. The insurers began to require prior authorizations for high cost testing, paperwork which, it was hoped, would give medical providers second thoughts before simply ordering these tests in a knee jerk fashion. But interestingly, while this eliminated some testing, the effect was minimal. It turned out that a majority of the testing was appropriate.

So the private insurance companies began to explore another way of limiting their financial exposure: rating or tiering the performances of its health care providers with high cost providers being penalized for their excessive use of resources by requiring patients to pay a higher co-pay to see them. The insurers hoped that doing this would prompt providers to limit their use of expensive providers and resources.

Fearing a backlash however, that patients would become upset that the insurers were forcing providers to limit patient access to certain specialists or to specific testing procedures, they also introduced the concept that providers had to meet certain thresholds for providing quality care as well. And while definitions for quality varied greatly within the system, many employers (purchasers of the insurance) were reassured that quality was important and, when it became apparent that the costs of providing health insurance to their employees could be brought under control by tiering, they began to demand that medical providers be tiered.

This system, the earliest form of value based purchasing, placed physicians delivering high quality care for the cheapest price in tier one. Those who provided high quality care but at a higher price were placed in tier two. And those who provided low quality care at high cost were placed in tier three. The higher the tier, the higher the co-pay for the patient to see that provider.

Intuitively most providers assumed that it was impossible to provide high quality care without it costing more. And, in fact, that was the tier that held the most providers. However, as a former member of tier one, I can say that this was not necessarily true. I spent most of my health care dollar seeing my patients as frequently as they needed to be seen. I did much of their initial assessment, forgoing specialty referrals in all but the most complex cases. And while the cumulative costs of my office visits was likely higher than most of my colleagues, the overall costs to the system were much less. Fewer and shorter hospitalizations were common because I could identify problems before they worsened. I could see them as frequently as necessary after discharge from the hospital allowing for an earlier discharge. And patient satisfaction was much higher because my patients could see me when they felt that they needed to be seen.

However, for many providers, pressed for time, with few appointments available for emergencies, there is the temptation to simply send patients to the emergency room for evaluation of acute problems. And if a medical problem is anything more than a simple diagnosis, the temptation is to send folks to specialists, with their attendant fees and testing. And of course, those specialists, for the most part, are never satisfied with testing that has been done at another institution, insisting that most tests be repeated in their own hospitals and clinics.

Well, if the solution to providing appropriate, less expensive care and leaving patients satisfied with that care simply required taking more time with those patients why have physicians tended, instead, to simply increase the number of patients seen and provide only cursory treatment at that. The answer will be addressed in the next segment.

Is American Healthcare Really the Best?

Have you recently been surprised at how quickly you or a loved one was discharged home from a hospital after an orthopedic procedure? Disappointed by the brevity of an office visit? By your inability to share all your concerns with a doctor during the visit? By your inability to see a doctor in a timely manner? By your inability to see a doctor at all? By the brevity of your rehab stay? By the rising cost of that care?

If you have been, you’re not alone. Welcome to the American Healthcare System, version 2.0, crafted for the twenty-first century. Where costs and cost controls have taken precedence over the quality of care delivered. Your quality of care. What this series of articles is designed to do is to take you behind the scenes, to uncover the inner workings of the health care system, to explain why what you experience is so far removed from the medical care that your parents and grandparents experienced.

But why should you accept what I have to say? Well, perhaps it is because I’ve spent over thirty years providing that care to thousands of adults as their primary care physician. Or maybe it’s because I have served also as an administrator of a hospital sponsored multi specialty group practice. Or because I have been a regional administrator for a large nursing home chain which provides physicians for rehabilitation facilities around the country. Or maybe it’s because I have served on the senior medical advisory boards for three of the top ten medical insurance companies in this country, as judged by the US News and World Reports rankings. Or maybe it’s just because I am one of you: a frustrated, disappointed consumer of health care.

Whatever the reason, I will attempt, in the next several articles, to pull aside the veil and explore the reasons why health care has evolved as it has, and what we have to look forward to. There are many who think that the solution to the current crisis in health care is to transition to a single payer system. That we should simply overhaul the present system and redesign it to better meet our needs. But there are economic forces at work which make this nearly impossible. From the regulation and restrictions of Wall Street and its banking institutions to the current, outmoded models of education in health care training to the current legal tort system, there are several rather insurmountable obstacles.

But to begin to understand the problem, we need first to look at some basic facts. According to a PBS News Hour report from 2016, the average cost of health care per person in the US was over $10,000. The next closest countries spent at least $3000 less per person. But, you say, the American Health Care system is clearly superior to any other system in the world. Well, not so fast. While we may lead the world in health care research and in cancer care, other metrics aren’t nearly as reassuring. Average life expectancy in this country is 78.7 years. Among other industrialized nations, the average is 79.8 years.

But, clearly, isn’t it true that we have more doctors here, that are more available to their patients than the other countries? Not so fast. Actually we have an average of 2.4 doctors per 1000 patients in this country while the average in the 34 industrialized nations surveyed is closer to 3.1 doctors per 1000 patients. What’s more, we have fewer hospitals and hospital beds than other comparable nations as well.

So why is our care so expensive? Are we getting our money’s worth? Because clearly the individualized care that we have come to expect has, as time has gone by, eroded. Oh, that’s not to say that we can’t find a “concierge practice” to provide us with a more customizable experience. A more Marcus Welby MD experience. But it costs much more money. And it doesn’t deliver what you might expect.

So here is the problem. The costs of medical care continue to escalate, while what we get for that money continues to dwindle. And while many of our health care policy wonks wring their hands over this trend, struggling with how to get the costs under control, the patterns continue. And we will, with the following articles, review how those wonks have tried to grab this tiger by the tail, and what it means for your health care experience.

Unlike many, I won’t try to redesign the system. I believe that if we can identify the problems, there are many, much brighter than I, that can look for solutions. But as you go forward, it may be helpful to place your health care experience into perspective, with the benefit of some insider knowledge.