Swamped: America’s Health Care System Is Drowning in Misery

                                            High Tide

Hardly anyone is happy. Patients aren’t getting the care they need. Doctors can’t give the care they want. Drug companies aren’t making enough money (ask them). Employers moan they pay too much for health care. Millions can’t get care at all.

                                            High Tide

Hardly anyone is happy. Patients aren’t getting the care they need. Doctors can’t give the care they want. Drug companies aren’t making enough money (ask them). Employers moan they pay too much for health care. Millions can’t get care at all. Millions more may lose the care they have after the Supreme Court rules on the latest Affordable Care Act case.

America’s health care system is drowning in misery.

And it’s about to get worse.

Except for insurance companies. Where injuries from flying Champagne corks have become an occupational hazard.

Physician Heal Thyself? Not.

Doctors are arguably the fulcrum of medical care. Without physician orders, nothing much gets done. Not many pills prescribed, few babies delivered, no hospitals needed, little surgery performed. The doctor-patient relationship is fundamental to health care delivery.  According to the writer Meghan O’Rourke, that relationship is shredded, torn by forces beyond control of doctors or patients.

O’Rourke has Lyme disease and an autoimmune disorder. She made a long journey to arrive at those diagnoses. O’Rourke endured years of cold exam rooms, indifferent physicians and futile testing. She describes the frustrations in an article for The Atlantic. The irony of impersonal, even hostile care, is glaring to her in this age of patient-centered medicine. She feels physicians and “modern medicine” are failing patients.

O’Rourke had an epiphany along the way: Many physicians feel they are failing patients too. Her article reviews a raft of books by dispirited docs. The books tell the doctors’ sides of the story, and the varied reasons so many are exasperated, demoralized, even suicidal. The first book is Atul Gawande’s best-selling Being Mortal. Gawande, a surgeon by training, writes of geriatric medicine. Old age and terminal illnesses are the dismal frontiers where health care’s inadequacies are often most glaring.

Sandeep Jauhar published DOCTORED: The Disillusionment of an American Physician several months ago. O’Rourke lists some of the problems Jauhar feels are plaguing medicine. Disrespect, pessimism, loss of prestige, loss of income and, most important, lack of time. All are related and all create an environment where, according to Jauhar, only 6% of doctors have a “positive morale”. Jauhar laments he has become “impatient…at times dismissive or paternalistic.”

O’Rourke goes on to mention or review books by Barron Lerner, Danielle Ofri, and one cowritten by Charles Kenney and Jack Cochran. The books chronicle waning empathy, rising anger at patients and pervasive cynicism.

God’s Hotel is the final book. Published in 2012, the book is Victoria Sweet’s account of her work at Laguna Honda. Laguna Honda is the last almshouse in America, in San Francisco not far from Golden Gate Park. Sweet is a physician and formally trained historian with a PhD in the history of health sciences from the University of California San Francisco.

Sweet practices “slow medicine”, the term she coined to describe the care she gives. Thorough, unconstrained by time and with meticulous attention to detail, Sweet often diagnoses significant problems many other clinicians have missed. She maintains slow medicine may be more efficient; more accurate, with less need for expensive technology and pricey drugs. Meghan O’Rourke says Dr. Sweet’s brand of medicine is what she was seeking. A doctor, “…who understood that a conversation was as important as a prescription; a doctor to whom healing mattered as much as state-of-the-art surgery.”

Awash

Most Americans have heard of Medicare. According to the Census Bureau, 15.7% of us are insured by Medicare. Many people know Medicare has scores of regulations, but few know the far-reaching effects these regulations have on their health care or the practice of medicine. Even people too young for Medicare are indirectly affected by Medicare rules. Often insurance companies and hospitals co-opt Medicare regs, forms and prices as default choices whenever possible to keep life simpler.

Medicare is managed by the Center for Medicare and Medicaid Services, known as CMS. (Medicaid rules are much different from Medicare rules.) Doctors must follow CMS’s rules when they practice medicine. At least if they want to get paid.

Medicare has good reasons for rules. Many rules are intended to get the best value for taxpayer dollars when buying care for older or disabled citizens. Fraud, poor care, and overpriced care have plagued Medicare for decades. CMS works diligently to prevent abuses. So it floods clinics, hospitals and doctors’ offices with an undammable torrent of new regulations. On what seems like an hourly basis.

Providers, especially small practices, can barely tread water now. And another deluge is on the way. Jason Shifrin writes for Healthcare Economist that a “regulatory tsunami” is headed for American medicine. Shifrin is quoting from a letter sent to CMS’s administrator by the CEO of the American Medical Association, James L. Madara, MD (http://bit.ly/1tuUioe).

The rules phase in over the next five years. All will set how much doctors (and other providers such as nurse practitioners) will be paid to care for Medicare patients. Federal bureaucrats see connections between inscrutable regulations and quality. Clinicians, not so much. Doctors aren’t convinced that more paperwork (or computer time) improves care. But failure to comply with the rules will result in docked pay.

Primary care practices aren’t getting rich seeing Medicare patients. Some struggle to break even. The cost of complying with new rules will be difficult enough. Pay cuts could range from 4% to more than 10% in the next few years. The combined effect will swamp many practices no matter how fast they keep bailing.

Rising Tide Lifts Some Boats

Cigna is a gargantuan health insurer, ranking 97th on the Fortune 500 2014 and fifth in the health insurance category. David Cordani is its president and CEO. Mr. Cordani discussed his company’s performance during an investor briefing late last month. He’s delighted. Cigna’s raking in more money than anyone expected. 

Turns out the ACA has been wind in the sails of big health insurers. Many schemes for “value-based care” were devised to lower costs for Medicare. The same tactics have meant clear sailing to higher revenue for commercial insurers.

Value-based care arrangements are sold as ways to move from paying doctors for care given or fee-for-service payments. Fee-for-service payments are condemned as the evil responsible for costly overuse of medical care. With value-based care, doctors don’t get paid unless patients get better. And stay better.

In fact, fee-for-service arrangements pay clinicians for work done. Value-based care may not. Value-based care is the insurance industry’s ploy for discounting clinicians’ reimbursement after the care has been given. No one should be surprised that medical students are shunning primary care residencies. How many of us are interested in jobs that don’t reveal the pay until the work is done?

That doesn’t worry David Cordani. He can take his $13.5 million in compensation and sail away with his insurance buddies on a rising tide of Champagne. While doctors and patients drown.