Walls and Barriers To Providing Health Care

“Innovative Health Care Programs?”

This seems to be the era of backwards-definitions.  “No Child Left Behind” means a diminished budget and fewer programs for child education. “Compassionate Conservatism” means cutting programs for the unemployed, the medical indigent and the hungry. “Strategic Defense” means a full-speed-ahead attack.

The “Innovative Programs” article talks about are mostly supplied by The Greenfield group, where improved medical care is provided if people  fork in some cash to get it.  Also “Harvard Vanguard,” who loves to be the first to do things.

Since there is nothing but Harvard hospitals on the reality TV show  Boston Med, I wonder if the Harvard Public relations people have descended to some all-invasive biological state, to infiltrate all media, and to try to get us to believe that they do things medically and surgically that are more advanced than other providers. 

This is not necessarily always the case…

After inspecting, organizing and participating in a variety of public clinics over the past ten years, I can tell you that no matter where I go — urban or rural, East or West Coast or Midwest — the practice of medicine is a hodge-podge of over-worked, burned-out employees including some scoundrels who try to get away with whatever they can to avoid work and get a paycheck for the time they occupy space rather than for the specific tasks they do.

The exceptions to this generalization are shining stars — saints, in my book — who actually care what happens to the patients left in their charge.

It is common to have a flooded waiting room — which insures that there will be NO confidentiality required by law — without an organized system to actually get the patients into one of the doctors (or more likely, “health extenders” who are de-facto doctors practicing without a license).

Just as common is to have a chief administrator who is either a secretarial person who was promoted for all the wrong reasons or a doctor who is trained to practice medicine and not keep a clinic functioning smoothly.

Doctors are slaves to the administrators — who are often the secretarial people at the front desk who answer phones and put calls through while a doctor is trying to deal with a patient, or who schedule a parade of patients popping in every 7 to 10 minutes and then shuttled off for three months before coming back for another few minutes.

Doctors are expected to sign the billing papers, and that’s about it. Prescriptions can be fudged and often are (using rubber stamped signatures or pre-signed pads distributed by the chief administrator to people the doctor has never met).

As our government has taken over more of the health-care payment, the clinics are enticed to bend the rules — double billing, having authorized people sign off on patients they haven’t actually examined, and other shenanigans.  With payments being reduced every few months, the clinics need to pull such stunts to keep their cash flow.

In the past year, I’ve been invited to evaluate several clinics that are NOT government (local or state) funded, but who contract to the government and bill them for services.  In each case I see the same mistake over and over. They try to build a private, for-profit clinic using the same model as the government welfare clinics.

There are certain things doctors can get paid for and a great many that they can’t get paid for.  I’ve worked in clinics where they only time I could bill for was “face time” with the patients. All the doctors in the clinic put in two to three hours of unpaid overtime per day just to keep their charts current. Phone calls to a pharmacist or a referral specialist were likewise “on the house.”

In one HMO known for aggressive cost cutting, the doctors had to supply their own pens and pencils, scotch tape and paperclips.

The biggest problem, though, is that doctors seem to be asked to make  more decisions with less patient contact. 

Now medicine has changed since someone told me this, early in my (American) surgical career, but I was told, from some study in the Midwest, that the average physician had to make the average medical decision on 70% of the “reasonably necessary” information.   There are, of course, reasons for this: patients forget.  Patients lie. You’ve probably heard that from Dr. House.

Some “Innovative” proposals are ludicrous.

Group appointments.  Wow, like that is really innovative.  I can’t imagine how many patients they had to interview before they found someone who said they enjoyed hearing how other people solved their own problems.

There is a word for this phenomenon.  It is called a “support group,” and does not usually welcome any presence from a professional.  I found out the hard way, as an overly-enthusiastic resident who decided to sit in on an AA meeting to observe.  I was told to get lost unless I wanted to go on a binge and become impaired.  The group was  extremely hostile to medicines, since they considered all drugs evil.

That being said, many cost-cutting organizations try to shed their needy patients by referring them to 12-step groups.  Medically speaking, “support” is not treatment, and this practice is unconscionable.

In real life, I have worked at several agencies that wanted their physicians to develop group appointments.  Before that, in mental  health, the notion of groups is one consecrated by use.  Plenty of examples, and admittedly some serious ways to help patients.  Institutionally, even within my residency training, I think (I was often a “cotherapist,” a secondary therapist present) I learned plenty.  But once I made the leap into private practice, I must admit I have not once heard any therapist, however noble and idealistic, discuss the idea of group therapy without talking about improving income.

Also in real life, whether we are talking mental or general health, patients get attached to their doctors.  There are studies that a patient will choose to wait longer for “their” perceived personal doctor than anyone who happens to be free.  Add to that the fact that every single patient known to me with whom I have discussed the idea of group patient visits has told ME exactly the same thing.

Basically, they say that telling the doctor everything that is going on is hard enough, and they would find it hard or impossible to do with people they did not previously know in the room. 

This doctor-patient thing is precious, and I have seen it diluted beyond recognition with “doctor extenders” and the like.  I suspect there are many people who feel some variant of these feelings.  I must admit the patients I have asked about this have usually seen me with nobody but the two of us in the room, and would look at any kind of a group meeting as a “stepdown.” One could always bring in new patients and train them to expect less. Lower cost doctor extenders tend to spend more time with patients and on patient polls, often appear more “caring.”  They may be able to answer common questions.  After all, common problems are, well, common. 

Me, I have re-diagnosed patients (and actually made them better) in several cases.  I could not have done this without spending a big hunk of adulthood in training in various specialties involving the brain, thereby omitting the hell-raising and failed marriages of my colleagues.  Moreover, thirty years of experience, well, it gotta be worth a few bucks.  There are some things a patient needs someone like me for and I do them pretty darn well.  I am also good at nurturing doctor extenders, and at teaching anybody who wants to learn. (“teacher” is what the word “doctor” means in Latin).

More people are looking for more doctor extenders.  Is anyone surprised?

I can name at least one job, where I was told my performance was “outstanding,” where they hired a nurse practitioner later as consultant instead.  Saved a lot of money, too.

Quality can never compete with cost — at least in the public health market.

However, nurse practitioners are now demanding — and getting — about the same money as a medical doctor.  In many cases, they have virtually the same duties and privileges, so why not?  Although, in some cases, they are over-reaching their authority.  The institutions probably rationalize this by thinking that paying a fine or two is cheaper than hiring the High-Priced help.

Okay, enough of that.  I continued to read my USA Today and found, also Monday August 16th, 2010, also on the front page (Health is no longer in Life section, for it is always on the front page now) “Grants to aid states vs health rate hikes.” Yep, there is an insurance “boost” coming and $46 million is coming so states can figure out how to regulate this.

Basically, the states in which this kind of authority does not even exist, are looking both for the authority to enforce something about these concerns over insurance rates, as well as personnel who actually know what is good and what is not. Since I have been unable to find any education on the internet that gives someone any education on — let alone any credential on — the determination of insurance rates, the best I seem to be able to do is to find people who are supposed to be experts on this and they seem to get their credentials from–insurance company.  Everybody got a rate determination system.

This is going into the void, to develop multiple state regulatory agencies from zero.  To tread where no minimally trained insurance man or woman has trod before.  (I you can hear the Star Trek theme in your head.)   I am not optimistic.  We have found a Brand New Way to spend money on  medical care without doing a single thing to improve the quality of that care. We have found a new way to build the bureaucracy, that can only increase building more bureaucracy.

People are dying.  People write columns in local newspapers reporting their doctors have told them “there is nothing we can do for you.” — Not due to any medical problems, but because they have no insurance or (worse) they DO have insurance, but it doesn’t cover that condition for some reason or another.

When I was a surgeon, we would determine a patient wasn’t a good candidate for a procedure if their heart couldn’t stand the surgery or they might not survive the anesthesia or there was some other type of serious medical risk.  We NEVER based our decision on ability to pay until the early to mid 80’s.

We need to be using most effective treatments, give people (like me) who have devoted their lives to taking care of people a chance to reach the people who need them.

Instead we are building a thicker and more impenetrable wall — a wall of people who make money from health care but add no value to the healthcare experience.

In the famous words of President Ronald Reagan, “Mr. Gorbachev, tear down this wall.”

Substitute the appropriate person for Gorbachev.

What I’m getting at is the need to tear down the financial wall between people and health care.  I do not care at all what kind of politics it takes.  Left, right, center, whatever, are only words.  People are dying, other people are making money off them and not helping.  These are not honest or decent ways to make money.  These people are parasites on the system, no better than thieves, and we are facilitating them in a consistent manner.

Would it be appropriate to say, “Mr. Obama, tear down this wall.”