Monday, September 1, 2008

Medical Problems

From a doctor friend:

Date: Sunday, August 10, 2008

Hello fellow thinkers and ponderers,

I have to say I feel a bit inept and uninformed in conversations with those of you who are well-read and have sophisticated levels of understanding about our world.

That being said, here's my experience:
1. A significant number of physicians seem to have lost interest in his or her skill and hate their lives. They find themselves filled with disdain for not only the entire system, but patients as well.
2. Of course, it wasn't always like that. Medicine used to be fun.
3. Many physicians, myself included, work to keep the fun alive. We're careful about not burning out, and take care to remember the patient is a human being.

I agree that the AMA keeps an artificial shortage of doctors. Emergency rooms are often crowded and waits can be hours and hours. My next available appointment for a new patient is in October sometime, for example. My colleagues up river stopped taking all Medicare and Medicaid patients over a year ago. These patients jam into community health center waiting rooms and are lucky if they get three minutes of a nurse practitioner's or PA's time.

All this begs the question: Why would anyone go looking for homeless patients to run tests on when the whole system is overrun? I can't imagine, but I believe anything I hear nowadays.

My experience is quite opposite. It's now so cumbersome and time-consuming to get an MRI, for example, that some doctors just forget it. Not good ones, but the less ethical ones. Why? Because BC/BS won't pay for an MRI without a litany of questions, forms, proofs and prior imaging studies. Ever wonder what your doctor is doing while you wait in the waiting room for 2 hours?? He is probably on the phone with a high school graduate attempting to explain why he thinks the MRI is necessary. (Well, an exaggeration, but there are secretaries and nurses embroiled in a fax battle with managed care.) Does the doc make money off the MRI? Absolutely not. I think it's a law or something... we can't be paid bonus money on lab tests, etc.

Scrutiny. Constant. "Report cards." Did you get your notes done, chart documented on time, orders signed? No? Well, you will have to be reported to the State Board. Would you like Fraud insurance? Why would I want that? I don't commit fraud. You certainly do! See that progress note with a bill attached by the billing department at the hospital? You have billed for 9 physical points checked, and you only have 8 written down! (This is not a mistake, but actually "fraud.")

Government has guys that travel around reviewing such charts looking for oversights in a crowded, overrun system. Whatever mistakes -- aka fraudulent entries or bills -- they find, they make 25%. One doctor said, "Why doctors? Why healthcare? I mean, why don't they go visit the Pentagon and look for overcharges on hammers or toilet seats?"

The truth is that I am scanning maybe 15 or 20 systems in a patient, not 9 or 8. But I can't take an hour to list my every thought or to "prove" that I really asked all the questions and ruled out all the differential diagnoses I was thinking about.

Finally, probably the biggest shocker of all: Most physicians don't need incentives to do a good job or be careful to "do no harm." We're aware we can kill someone with a pen and prescription pad. We want to help patients get better, that's all.

On the other hand, why do physicians order MRIs, CT scans and unnecessary tests? We all practice defensive medicine. Better get an XYZ test because if you miss that condition you're sunk. It's called "standard of care." Defensive medicine costs some number of billion dollars per year. Some 50% of physicians will be sued.

Answer? Americans need to be incentivized for good health, maintaining healthy weight, not smoking, lifestyle modifications. We need to get money in our pockets every year when we do. BC/BS is like Exxon-Mobil when it comes to making money. Medicaid's administrative costs are only about 5%, while BC/BS's are some 25-30%. See the skyscrapers in New York made of glass and steel?

I'm not against physicians making decent salaries, after dedicating long hours and years to what usually begins as an altruistic pursuit. Most docs will never be rich -- not like basketball players or money market fund managers or CEOs of insurance companies or oil execs.

Well, that's some of my experience. I do not feel "protected," and I don't feel any lack of criticism. I have 900 patients, and I hope they will be OK. Ask Andy how many times I have called in sick. I have excused myself from an exam room to throw up, washed up, then returned to finish treating a patient. I have gone to work the day after sobbing 12 hours over the death of my mother. We can work all night and all day without complaint. Many of us sleep with pagers or phones under our pillows so as not to wake our spouses if we get called. Almost every doctor I know is the same. The only thing that makes us tired, like Andy says, is the paperwork.

Yes, there probably are doctors and hospitals committing fraud, but rarely.

Sorry it's so long. :-( thought you guys deserved a real answer :-) now to enjoy the weekend.

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