Friday, April 9, 2010

Health Care Reform

As a doc, I often get asked the question, what do you think of the new health care reform? I can give the usual answers, "Well we needed to do something." "I am cautiously optimistic." These are true statements. The plight of the physician in 21st century America seems at best to be uncertain. That is what it is: a plight. It is hard for me, just like everyone else to predict exactly what is going to happen. It is so convoluted and complex, thousands of pages and issues. So many gradients and steps. I do know as a society we are more in the "here and now" and all about immediate gratification, more than ever. That is no different in the personalities of politicians and lawmakers, than it is in anyone else. We are all about image and appearance in the here and now.
Being in the here and now is fine for meditation, but I am not so sure it is fine for making laws and planning for future society.
So the facts I can speak of are true and relative to my plight. I know right now I would be deathly afraid, like so many Americans, not to have health insurance. Life is unpredictable, and you can't live your life and plan for castatrophe but on the other hand, things do happen. Anyone reading this knows that. Hence things like AD in a family member etc. Hence many of us know this and maintain health insurance as best we can. My family is in pretty good health and for an average policy we have to pay nearly a thousand dollars a month. I am quite certain that those premiums will go up considerably with health care reform. Once again trying to do the right thing and take care of your family, often seems to go with punitive consequences.
That issue of the insured premiums having to go up in cost to cover those without insurance is an absolute farce. I know that many people only access care in the ER and don't pay a bill; those debts go somewhere right? It would be most interesting to truly trace a dollar in cost for health care. If the insured covering the uninsured and thus paying higher premiums was actually true and not a "catch-all" chant, the insurance industry would be more like: breaking even. That is actually not the case, is it?
From the perspective of a physician practicing on his own in Northern Minnesota in 2010, here's what else I can tell you as fact.
Right now it is almost impossible to treat a patient with a prescribed therapy and medication without fighting with an insurance payer to get that prescribed therapy covered. Every single day I fill out forms, requests, appeals, protests, to try to get a patient their appropriate medication. You don't get to be a doctor anymore, because that struggle takes lots of time, so it takes you away from trying to take care of patients.
You struggle with people that are sitting on the phone in some cubicle, who don't really know anything about patient care and most importantly the name and the face and the life of that patient or any patient of a doctor to whom they are denying care.
They are working right; trying to make a living just like everyone else. Public sector and private sector employees. They are basically taught, in so many words that the physician is the "bad guy". It is ingrained and instilled in them, at their little week-long training seminars at some Radisson or Holiday Inn (lunch included), that the physician is somewhat of an advesary; trying to prescribe expensive and unneccesary treatments. Now they might not fundamentally have that "chip-on-the-shoulder" prevasive American attitude about doctors, yet it is pretty easy to tap into. It get's you kind of fired up and believing. Plus you get to make a living. It is almost justice, yet no name or face to the patient, the person needing the treatment. It's not new and it will get worse, I can see it everyday in my practice.
One of the saddest parts of the plight is that the patient holds the doctor accountable. It is just human nature. So you have the insurance company demanading that you prescribe what they want, You know as the doctor, it is not the optimal therapy. You advocate and fight for your patient. We used to win those battles but over the last year, we are consistently starting to losse those battles. no matter how hard we fight. In the end it is still about the doctor-patient relationship and that human connection, not the insurance company. In the end, The doctor has let the patient down, not the insurance company, More devisive, more advesarial, than ever. I promise you: that will only get worse. And the distribution and justice and equity and fairness, just does not loom on the horizon with health care reform.
I think it was absolutely pathetic when President Obama had all those people, (physicians) standing around in their white labcoats, for photo ops. How stupid do we really think the American people are? How demeaning to physicians. Sort of like a beauty pageant or a dog show. I mean more importantly those people in white lab coats standing around for the photo ops, (physicians right?)- who exactly was taking care of their patients that day? Maybe their partners, right?
Heres another fact, in Minnesota I still get to keep paying an extra 2% income tax called the provider tax, a tax to cover the uninsured. If you take care of patients and make a livng at it and don't work for some large corporation or institution, where it is all rolled in and you simply get a W-2 at the end of the year, well then it is not an income tax right? For me it is an income tax, since I derive my living directly from caring for patients. No filters, no employer. I promise you it would feel so much better if we actually covered everyone in Minnesota, but there are still thousands without insurance. So where does my extra income tax, (2% back to the state for taking care of patients) go? God only knows. If only we could get rid of the small or private practitioner everything would be better right? A dying breed. A thing of the past. Sort of like the airlines or banks. We only need a couple of health care entities, corporations, that will improve health care right? I mean look at how good the banks are doing, and the airlines.
Let's look at the VA, the largest health care entity in the USA. In my experience from patients I talk to, you either have a fantastic health care experience or an awful harrowing one. That's just what I see and am told directly by patients. Not too much equity or fairness or consistency, just sort of hit or miss. The private sector is not much different. The idea seems to be: more people managing health care, more executives, more people employed in the health care industry, trying to make a living, governing the care. (oh and going to lots of meetings, focus groups, committee assignments, clip boards, Coach briefcases, company or federal credit cards, hotel check-ins at government rates or corporate rates, for more committee regional meetings and retreats all around the country, first class or coach and basically walking around as health care executives)- somebody has got to pay for ALL that. No patient name, no face.
Eventually there will be no choice, there will only be a couple of entities, and payers, governing all of health care. Does less choice improve quality and the health care experience? Maybe, maybe not. I know as human beings, it is nice to have options, choices. Right? Sort of helps the human spirit. Less choice and more monopoly is not the same as justice or decent care, but few seem to get that.
Here's another FACT I can tell you. Remember that mantra, ever so popular, "You get to choose your own doctor". Well here is the honest to God truth in my plight. There is this entity in Minnesota called GAMC. It is an arm of Medicaid. Starting June 1st, patients with this insurance, have to go to a designated provider, a care coordinating organization, a big entity of which I am not part of-(to thy own self be true). There is a clump of money to cover all these patients given to large health care entity: no more no less. Some patients cost a lot to care for and some don't cost much, right? If you come in under cost at the end of the year you win if you spend more taking care of patients, you loose. It is called capitation. A ceiling or top. It is something I first heard of in 1990, back in New York state during my residency. It didn't work back then and it went by the wayside,- most states learned from that, but now it is back. Nice incentive right?- That good old capitation.
So the bottom line with this GAMC is that patients with this insurance, many that I have followed for years, are not allowed to come and see me anymore. They have to go somewhere else. Not a problem right; the large institutions have good doctors, no question, and also lots of other people in the doctor role, providing medical care, like nurses, and physician assistants and things. Cheaper and all, and no of course it is not watering down the care. No problem. But if you even remotely imply that maybe the physician still offers something the nurse prescriber does not, you get annihilated. That is the most politically incorrect thing of all time. The fingers point and the physician looses. Arrogant, prima-donnas that those doctors are, right? Easy to be politically correct on that one, patient does not get too much say.
So my patients with GAMC don't get to come and see me anymore, they get to change their doctor sometimes after many years. The government provided insurance says so. No one notices that good outpatient care prevents inpatient hospitalizations. Wow.
I wrote my senator, Yvonne Prettner-Solon. she wrote back and said she didn't like it; she voted against it, was on my side and that was it. She is a democrat, in Minnesota, unbeknown to most around the country the democratic, party is called the DFL. It stands for democratic farmer labor, a remnant of days gone by, but it sticks. She is a nice person and a psychologist- my state senator, but there was not much she could do for my plight, and more importantly the plight of my patients. Roll the dice, hope for the best, lets how it shakes down. PATIENTS DO NOT GET TO CHOOSE. Sorry but that is the honest to God truth: One little example in my little corner of the USA on the Western tip of Lake Superior. It is really happening, and there is a tremendous momentum of more to come.
I called my local news; it was pretty easy to get interviewed. It was actually easier to get on the news, than it was to get an appointment with a physical medicine and rehab doc at one of the large institutions for the herniated discs in my neck. No lie.
So they interviewed me. I talked for 20 minutes. I got a 10 second sound bite, that at least covered my most important point. The physician-patient relationship; the therapeutic alliance is still the most important thing in health care.
The tease for the story was "GAMC creates headaches for some private physicians in the area". Nice divisive tease right? Make it about the doctor, subtly reinforcing that adversity. They could not mention the fact that it is about the patient and what that it will all actually mean for those human beings. It is something that it is actually significant for those human beings, those names and faces, that have to, after years, disrupt their care. If we make it about the physician having a "headache", we can deny the reality of what is really happening right? Get lost in our emotions and subtle reinforcing of that physician adversary. Oh well it is only the media, but I tried. It is not like we believe everything we here on TV and read on the Internet, or is it?
Put it this way, I came from a long line of physicians, my father who died when I was sixteen was the first; he inspired a lot of others. My son is 14, I always had a vision of him maybe going into medicine. I guess he would be better off becoming an attorney, he will do what he does, but I am not steering him towards medicine. I just can't do it. I see the doctor and the healer, the ideal, simply deteriorating. Every single day, every year, every decade. That is so very sad.


karen said...

Thank you. I actully understood what you said in this post. The first clear look at health care reform.
I had to stop working to care for mom. Which means I lost my insurance. I payed for it myself till my savings ran out and it was just to high with all moms needs with only her SS check coming in. I pray everyday I don't get sick or need med. care. All I can say is it is in Gods hands now. What will be will be.

Joseph Potocny said...

You are wordy, I thought I ran on. Thanks for your points of view. Me personally think Obamacare is a disaster waiting to unfold. But that is what our country asked for, now let us see. I am glad I have AD & FTD, i will forget this bs all in time, not a bad trade off.

Talking about the book with the Lake Superior wind....... a calm day