There are an awful lot of reasons that led up to my eventual resignation from an eleven year career in clinical medicine. I don’t know that any one of them is more important than the other (it really just depends on which day you ask me). One that stands out for me though as a universal problem shared by millions is Managed Health Care, and the imposition it has posed on physicians and patients alike is enormous. What happened to health care in this country anyway?
A BRIEF history of managed care:
The origins of the first managed care efforts in this country date back to the early 1900’s, when prepaid physician services started showing up in a few select industries and health care organizations. In 1947, the physician-run American Medical Association got walloped with an anti-trust violation conviction for their efforts to limit physician involvement with group health plans. The movement gained momentum and really got some teeth when the HMO Act of 1973 was signed into law by President Nixon (way to go, Dick), which used federal funds to promote the growth of Health Maintenance Organizations (HMOs). The backlash really caught up in the late 90’s, when US per capita spending started to rise again, despite the mission of managed care to reduce heath care costs. US healthcare expenses continue to eclipse the national income, and have been increasing approximately 2.4 percentage points faster than the annual GDP for the past 40+ years.
Ironically, while the whole point of managed care was to reduce healthcare expenses in this country, insurance company executives have continued to earn grossly exorbitant salaries. The top executives working at the country’s five biggest for-profit health insurance companies earned compensation of almost $200 million in 2009. Cigna insurance company paid its outgoing and incoming chief executives a combined $136.3 million that year.
So, you ask, what do we have to show for all this?
Booyah!!! We suck!!!
Now you have to layer on top of this healthcare cost crisis the fact that doctors have really had to change the way they practice medicine. Managed care means less time spent directly with patients, and more time spent on non-clinical activities (i.e. paperwork). The 2011 Medscape Physicians Compensation Report generated survey results from almost 16,000 physicians across 22 specialty areas regarding income and practice parameters. Primary care physicians have the shortest access time per patient, with a median visit time of 13-16 minutes per patient. (For the record, pediatricians averaged more patient visits per week than any other specialty.) 17% of primary care docs spent more than 20 hours a week on paperwork and other non-patient activities, and less than half of primary care physicians would choose to go into primary care again if they had the chance to do it all over again.
Quite honestly, this turns my stomach. And I already got out of clinical practice.
I remember my own horror stories quite vividly. Like the day I spent SIX HOURS on the phone with an insurance company trying to get one of my patients a badly needed MRI. It was my administrative day, and I realized that this company’s strategy was to walk you through a twenty-minute phone tree, and then conveniently “drop” the call a few minutes in once you finally connected with a live person. It became a point of pride that day. I put the speakerphone on, and did my charting and admin work for six hours while alternatingly listening to hold music and getting hung up on. Finally, in the end I wore them down and they relented and gave me an authorization code for the scan (the call being conveniently disconnected half way through my receiving the authorization number and necessitating yet another call back.) Apparently, they were quite nasty to our billing specialist who had to talk to them to get the final information, like I had somehow done something really, really selfish in getting my patient the procedure he needed. And just for the record, it was one of only two MRI’s I ever ordered as an attending physician, lest you think I was somehow ordering these tests willy-nilly and eating up all our healthcare dollars.
I also had one insurance company deny authorizing my patient an EpiPen. If you don’t have any experience with EpiPens, they are automatically injecting syringes pre-filled with epinephrine that patients carry with them who have life-threatening allergies to things like bee stings, peanuts, etc. They keep people from dying. I could not imagine on what planet and in what solar system an insurance company would have a sane reason for denying a severely allergic patient one of these. And the worst part was they absolutely had to talk directly to me about it. They couldn’t discuss it with one of our residents, our nurses, or our nurse practitioners. I had to take time out of my excruciating schedule to have a lively chat on the phone about why it was important for my patient not to croak.
Pardon my language, but this is a f**king crime. I did not pay a fortune and spend four years in medical school to be trained on how to deal with the insanity of managed care. And I don’t think my patients would have wanted me spending precious time learning how to appropriately fill out a prior authorization form, when I could be learning about medical disease processes. Yes, people are specifically trained to deal with managed care, but often enough the insurance companies make demands of us that they simply won’t accept from other staff. And if we don’t comply, our patients are the ones that pay the price. If I put my foot down and say it’s inappropriate for an insurance company to require I give a pharmacy my DEA number for a non-narcotic antibiotic prescription just for tracking purposes, my patients simply won’t get the medication they need.
Having recently retired myself from clinical practice, I will be the first to admit I miss my colleagues. I desperately miss my patients (well, most of them anyway). But I don’t miss this. Not for one solitary moment. My heart goes out to my colleagues who are still trying to practice actual medicine in the face of mounting adversity. Keep fighting the good fight.