Bureaucracy versus medicine
By Dr. Steven Fera for Save Our Health Care
Primary care in this country is at a critical juncture. The
causes are multiple, but government reforms, demands of private payers and
corporate employers, the burden of pre-authorization, and the introduction of
electronic medical record (EMR) systems are all important contributing factors.
To the rescue?
In the 1990s, managed-care plans emerged which greatly increased insurance company profits at the expense of the physician. Hospital executives and entrepreneurs have capitalized by organizing physicians into groups called Accountable Care Organizations, collecting a substantial percentage of collected income. Nowadays, physicians are required to use electronic medical records, which has transformed daily workflow.
In many
cases, patient visits are dominated by time spent engaged in data entry, which
requires searching for the correct medical diagnostic code (currently there are
over 69,000) and billing code, along with including sufficient medical
“information” to qualify for payment. The companies that developed them are
reaping significant profits from hospitals and physician practices. Whether
this enhances quality or simply undermines the doctor-patient relationship
depends on who you ask.
Over the past decade or so, the costs of practice have outpaced increases in reimbursement. Moreover, administrative demands have steered a majority of physicians into employment models, where they have often found that “protocols” and “productivity” were more important metrics than “quality,” leading to both physician and patient dissatisfaction. A rewarding and successful doctor-patient interaction requires time, a luxury many practitioners can no longer afford within the constraints of shorter patient visits.
Physicians often find themselves doing a lot of tasks that could be handled by support staff without a medical degree, if only sufficient staff were provided. But support staff isn’t the biggest issue. For many primary care physicians, it is the loss of time with patients, declining reimbursement rates, and the erosion of prestige of primary care.
The nature of the reimbursement system has historically valued procedures over cognitive services. Despite talk about value-based care for many years, we remain a system that is still mired in a fee-for-service model. And all too much of their day is devoted to EMR systems, obtaining pre-authorization, coding, and completing paperwork.
As a result of these
issues, the numbers of newly trained physicians entering primary care are not
keeping pace with those retiring or leaving primary care. Medical students will
continue to pursue higher paying specialties as long as reimbursement rates for
primary care are below the average physician salary. For today’s medical school
graduates, educational loan debt also strongly factors into this decision.
Current trends do not appear to provide satisfactory solutions. Hospital employers have resorted to replacing physicians with less expensive nurse practitioners and physician assistants, but it remains unclear how this will impact the quality of care, especially in patients with complex, multisystem diseases.
It is too early to tell whether organized labor will provide an effective voice for physicians, but this is currently an area of active exploration and is already available for some physicians in residency/internship training programs.
To improve quality and access, we need to unchain
health-care providers from the bureaucratic requirements that are strangling
them fiscally and temporally. Reimbursement reform is essential, but so are
measures to increase physician time spent with their patients rather than their
computer.
Dr. Steven Fera is a retired cardiologist and the
opinions expressed are his own.
