You Make the Diagnosis...an excerpt from my upcoming book, Distracted: How Regulations Are Destroying the Practice of Medicine and Preventing True Health-Care Reform (release date June 27, 2017)
May 29, 2017
If you want to learn what is wrong with the American health-care system, just follow any doctor for just a short time. It will soon become obvious. The following common scenario should make things clear.
The patient is taken to the exam room and the doctor attempts to pull up their medical record on a computer in the corner. But because of an Internet slowdown, there is a substantial delay until the record comes up. To fill the awkward void created by these wait times, the doctor and the patient chit-chat about how bad things are in the world, especially in health care.
When the patient’s record is finally displayed, the doctor has to open and close multiple screens just to view basic medical information, which slows things down even further. It is also distracting, especially as the doctor attempts simultaneously to interact with the patient. This interaction is important because it allows the doctor to pick up important clues to what is wrong with the patient, but also because after the appointment, the patient will be filling out a government-mandated satisfaction survey that partly determines how much the doctor gets paid. Not surprisingly, staring incessantly at the computer screen rather than making eye contact with the patient often results in lower satisfaction scores.
While the patient discusses their medical history, the doctor’s mind wanders, as it often tends to, to the incredibly complicated, but government-mandated, formula used to calculate how much should be charged for the appointment. As required, the doctor tries to keep count of how many problems the patient complains about, the number of questions that were discussed in relation to each of those problems, and even the number of body systems that were reviewed in each case. As the formula specifies, the more that is discussed, the more that can be charged for the appointment. The same goes for the physical exam—the more body parts examined, the more that can be charged, so the doctor tries to keep count of that, as well. Sometimes during computer slowdowns, the doctor fantasizes about a patient with an extra arm and an extra leg, and wonders how much she could charge for that.
The doctor appropriately surmises that some testing would be useful. But the patient says he would rather hold off on any testing. He has a high-deductible insurance policy, which means that he would have to pay for any tests out of pocket. Both the patient and the doctor again take a few moments to complain bitterly about all of this. This extra time complaining has become such a regular part of many appointments that the doctor has even daydreamed about a system where she could bill for complaining. In her dream, she gets rich quickly and then retires!
When they both finish complaining, the doctor also remembers that Medicare is now monitoring how many tests and treatments she orders and comparing the cost of her medical care to that of other doctors. Beginning in 2019, there will be financial penalties if her care exceeds the average, one of the horrors contained in the new government payment reform plan, the Medicare Access and CHIP Reauthorization Act (known better by its abbreviation, MACRA). She doesn’t want to be penalized, so, the doctor thinks, to hell with clinical relevance and the best interests of the patient. She is not ordering any testing.
Since the doctor won’t have the benefit of any tests to confirm her suspicions, she just makes her best guess at the diagnosis that is most likely. But she also takes the time to explain that she just might be missing the far more deadly (though somewhat less likely) diagnosis she might have found had she been able to get any testing. This understandably upsets the patient, who requests some Valium because he is so distressed. With the threat of a negative patient satisfaction score looming over her head, the doctor gives him the Valium.
The doctor also prescribes a medicine based on her test-free diagnostic guess. She sends the prescription, which is a commonly used generic medication, to the patient’s pharmacy, but then receives a call from them to say that this medication is no longer available unless she first obtains prior authorization from the patient’s insurance company. She gets on the phone and waits for ten (unpaid) minutes to get the authorization, but then gets cut off without completing the process.
On a completely separate, but very important, matter, the doctor also happens to note that the patient’s blood pressure is quite high (she assumes hers is too at this point). When she brings this to the patient’s attention, he admits that he stopped his blood pressure pills because the medication was no longer on his formulary.
This is a problem for the patient, obviously, but it’s a problem for the doctor now as well, because the government has started collecting and compiling statistics that rate the quality of a doctor’s care based on such things as the blood pressures of patients treated for high blood pressure. Beginning in 2019, as part of the previously mentioned MACRA program, there will be financial penalties for low quality ratings.
So the government assesses penalties if the patient’s blood pressure is not well controlled, even though the patient’s insurance doesn’t cover his blood pressure medication. The doctor and the patient are caught between a rock (the government) and a hard place (the insurance company).
With so many factors working against them, and especially in light of these looming penalties, the doctor begins to think it would just be better if the patient (whom she has been seeing for years) went somewhere else for his medical care. Why should she be penalized when there are so many factors entirely beyond her control that keep her from adequately caring for such patients?
Frustrated, distracted, and now running late for her next appointment, the doctor decides to write up her notes later that night, or maybe early the next morning, because the computer system is just too slow to do it while she is seeing the patient. She knows that she will probably forget important points by the time she gets to it, especially considering all of the distractions she has encountered. She and her colleagues now spend hours after they are done seeing patients trying to catch up on the computer, and this is beginning to take a terrible toll. But that’s just how it is these days.
As the scenario plainly demonstrates, medical professionals are increasingly distracted by a combination of overly burdensome and needlessly complicated government regulation and a health insurance industry that systematically denies necessary medical care.
I am not a traditionalist. There was no golden era of medicine to which I think we need to return. Taking care of patients has always been challenging and it always will be, even under the best of circumstances. But years ago the process was a hell of a lot more straightforward than it is today. I am not advocating a return to the past, but what is happening today is unacceptable. We need a better way forward. Our lives may depend on it.