Taking issue with health care reform
I appreciate the difficulties of working with Washington, as presented by Robert Doherty [“Monday morning quarterbacking doesn't score touchdowns, “ ACP Internist, September 2010]. On the other hand, I think organized medicine in general and especially those who practice in small groups made out badly in the recently passed health care legislation.
I am not mollified by the fact that we took the “high road.” It becomes more burdensome and expensive to stay in private practice. The new legislation rectifies nothing and there are new hoops to go through. Sustainable growth rate (SGR) reform remains iffy at best. Why should Congress act now? I struggle to keep staff and make payroll. I don't see that becoming easier. Down the road all I see is a point where I will just close the shop and retire, or go to work 9 to 5 for big medicine or the government.
Mr. Doherty's article is a nice reminder and summary of the history of the SGR and the problems we face in getting it repealed. However, it implies that the current bill will score “touchdowns” in improving our patients' access to and quality of health care. Field goals would seem our best hope currently. We could even end up with a safety.
The bill that came out of Congress is a pig and no matter how much jewelry you adorn it with, it is still one ugly critter. Cost containment is only addressed with a huge dose of wishful thinking and the assumptions on eventual cost are highly suspect. The failure to address the SGR is fundamental to the likelihood of general internists like me remaining as participating providers in Medicare and is unfortunately likely representative of the approach to reimbursement that we will see in the program on an ongoing basis. The 10% “bonus” is so highly conditioned that many or even most of us will likely see nothing. Additionally, 10% on top of a 40% to 50% effective cut in reimbursement over the last 10 years isn't much to brag about. If you cannot assure a reasonable wage to physicians on such a huge block of patients up front, it is highly likely that the system will continue to reimburse physicians at a rock-bottom minimum for as long as it can get away with it.
The myriad benefits envisioned in the recent legislation will be illusory if fundamental concepts of provider reimbursement, cost containment strategies, etc. are not adequately addressed. The best, perhaps the only, time to do so was at the start. The glittering jewels of improved access to care, improved coverage for prevention, effective and affordable treatment of illnesses, etc. may turn out to be worthless plaster if these structural issues are not resolved. You don't address the foundation of a house after you've already started interior decorating.
Reimbursement issues are fundamental to the success of the entire enterprise, and not dealing with them appropriately early on was a huge mistake, no matter the political calculus involved. It is possible to end up with a result that's even worse than the mess we have now. Buying into what passes for wisdom inside the D.C. Beltway is a great way to build a house of cards, not a health care system.
Organized medicine, including ACP, got it wrong.
A recent item [“Health care reform's effects on physicians described,” ACP InternistWeekly, Aug. 24, 2010] stated, “Health care reform will increase the appeal of primary care as a career and push physicians toward practice integration or hospital employment.” This implies that the introduction of the medical home will induce doctors to practice primary care (I trust we really mean internal medicine). I strongly disagree. Most doctors are in small groups and cannot afford the huge expense of the medical home as it is currently being touted. There has not been any promise of significantly higher payment for office visits. The article talks about the new paradigm being more appealing, yet everything about it pulls doctors away from the patient.
Cuba and ideology
I read your recent article about Cuba's national health system [“Cuba is just across the water, but medically, a different world,” ACP Internist, September 2010] with significant interest and was dismayed that Paul K. Drain, ACP Associate Member, could not be more wrong.
I do not know how to correct such misguided perception other than to offer a truer vision of reality. Allow me to refer you and Dr. Drain to Katherine Hirschfeld's July 2007 article in volume 2, issue 3 of Cuban Affairs Journal. This article provides a more accurate portrait of current health care in Cuba and receives more substantial support in Dr. Hirschfeld's 2008 book depicting the history of Cuban health care.
It is distressing that Dr. Drain's adherence to error perpetuates the distortion initiated by Herbert Matthews and, more recently, Michael Moore. Ideology, in the hands of those who would not suffer the consequences of their beliefs, is sanctimonious and fatal, when in error, to those directly affected.
As a medical anthropologist who spent nearly 10 months in Cuba researching health care in the late 1990s, I can say with some degree of certainty that while Dr. Drain may have excellent medical credentials, his very brief visit to Cuba does not qualify him to make accurate or reliable generalizations about the nature of the Cuban health care system. Unfortunately, these kinds of misrepresentations are common. Many medical and public health researchers refuse to venture beyond uncritical reiteration of Cuban government health data in their analyses. The fact that these errors are so common, however, does not mean that they are acceptable in a scientific publication.
Dr. Drain's representation of Cuba is gravely inaccurate on a number of levels. His portrayal of medical practice, for instance, does not include such vital information as the tendency of the Cuban government to arrest and imprison doctors or medical students who publicly protest abominable working conditions, severe shortages of vital equipment and supplies (including soap and disinfectant) and a paltry monthly salary of $25 U.S. Dr. Drain also neglects to mention there is no legal right to privacy in Cuba, including privacy in medical encounters. There is correspondingly no notion of patients' rights anywhere in clinical medicine, and no informed consent protocols for medical research. As a result, the potential for major human rights abuses within the Cuban health system is quite high. Patients and doctors are profoundly disempowered and unable to organize any sort of collective protest against heavy-handed and repressive government intrusion into medicine. Given that human rights activists on the island are viewed as dangerous subversives and frequently jailed as “counter-revolutionaries,” it seems likely that human rights abuses within Cuban medicine are severely underreported.
Dr. Drain clearly means well and is genuinely concerned about the problem of global health inequalities. These are obviously pressing problems that merit attention from North American health professionals. As Fidel Castro himself has recently acknowledged, however, the Cuban model is no solution.
Your interview with Paul Drain was fascinating and very much as I found Cuba, when in 2001 as president of the American Medical Women's Medical Association I took a group of 50 individuals interested in health care to the island. I would like to mention two subjects not covered in the interview.
First, one of Castro's first tasks was to increase the literacy rate in Cuba, which is now 97%. Having literate residents was essential to launching a universal health care system.
Second, alternative and complementary medicine is utilized on the island. To Cuba's credit, its scientists are trying as best they can (as are ours at the NIH) to determine if a scientific basis exists for any of the plant remedies the doctors are using. Our group visited the vast Ciénaga de Zapata (Zapata Wetlands), designated a UNESCO biosphere, where we toured the center for medicinal plants and met with the researchers working there cataloguing, characterizing and growing plants. We also visited the Natural and Traditional Medicine Clinic and listened to lectures both by the Cuban doctors from the faculty of Medicine of the Province of Matanzas and some lectures by doctors in our group as well. With the embargo lifted, there could be more collaboration and scientific exchange, especially in this area.
EHRs not a cure all
I'm afraid Dr. Ralston's wish for perfect software [“EHRs could solve resource overuse, free up physician time, “ ACP Internist, September 2010] to manage administrative “scut work” will remain in his “alternative universe” for the time being.
I justify my pessimism because corporate nature and the human nature of its health care executives will always seek to give an advantage to their enterprise and maximize profits. Any piece of software designed to more easily navigate complex systems will reflexively result in a rejiggered system that is even more complex; if the software's application is to obtain, record, and/or transmit data, it will result in a reflexive demand for, you guessed it, more data that insurers crave and that we internists will be required to provide. In the words of the late comedian George Carlin, your “stuff” expands to fill the space available for it.
It's not a good idea to view the EHR as the answer to all our problems. Most EHRs are benefitting insurers first by codifying and editing CPTs and ICD-9s and allowing them to interrogate the EHR for data collection and pay-for-performance/quality measures; benefitting institutions second by easily documenting every often trivial aspect of each patient encounter; and benefitting institutions and finally physicians third by improved coding and billing to maximize revenue per encounter. I've heard in informal conversation that only the next generation of even more expensive EHRs will offer significant clinical decision-making assistance.
Formulary requests and demands are getting more outrageous and onerous each day. Patients are annoyed and physicians are increasingly frustrated. When insurers and pharmacy benefit managers fax us to demand prior authorizations and formulary compliance, our response should be less acquiescence and hiring of additional administrative help, and less wishing for the latest greatest software for our EHR to manage these demands. Our response should be more rational resistance.
Insurers, pharmacy benefit managers and radiology review companies have millions invested in the status quo, and hypocritically, it's quite rare (less than 5% of the time) when these expensive systems deny me or my patients coverage. I doubt these same insurers would cover a medication or procedure found to be effective only 5% of the time.
At times I involve my patients (sometimes to their profound annoyance) in the formulary and radiology prior authorization process. I ask them to confront their insurer or company human resource office when a medication they have been taking for several years is suddenly and often arbitrarily no longer covered, or their co-pay doubles or triples. I request they stay with me and listen in on speakerphone when I request a prior authorization for an MRI my patient is demanding—all 10 to 15 minutes of pleasant, really useful conversation. Lately I've taken to demanding that the first prior authorization clerk I speak with is the one empowered to grant the authorization. If not, I demand they immediately connect me with the one person who will. To my surprise, this process sometimes actually works, saves time, and engenders in me a glimmer of empowerment.
I appreciate Dr. Ralston's best intentions, and hope his wish for the ultimate software app falls out of an alternative universe and installs itself in his laptop. Until then I prescribe less acquiescence, and more resistance.
Mindful clinical judgment
In response to “When patients don't tell all: The diagnostic challenge, “ [ACP Internist, October 2010], I recall a similar situation. I was covering a military emergency room on the West Coast when a 12-year-old child was brought in by her mother and father because of swelling and pain of her right foot. The young women specifically denied any trauma. I obtained an X-ray that revealed a sewing needle just below the skin of the bottom of her right foot. A surgical consult doctor placed her foot under a bright light and said, “I think I can see the tip of the needle,” and the surgeon gently and deftly removed the entire intact sewing needle in one swift motion.
I sat down with the young patient and both her mother and her father and said, “Now, please enlighten us!” She said, “Doctor, I knew I stepped on that sewing needle. I was afraid to tell you since I was afraid you would then have to cut my foot open!”
If you asked me, “Why did you obtain a X-ray of her foot in the absence of any history of trauma?” I would respond, “Clinical judgment, which all of us in the American College of Physicians use each and every day of our clinical practice!”