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Physicians, You CAN Have It All: How To Run A Business And Also Practice Medicine

It’s no secret that physicians are experiencing burnout at an exponentially increasing rate in our progressively bureaucratic healthcare system. Many are looking for “alternative careers” as their salvation. I receive emails from physicians all the time, asking for advice about getting out of clinical medicine, since I have spent a few years outside it myself. As my own career pendulum has swung from full time clinical work to full time editorial and/or consulting work, I’ve found that the best mix is somewhere in between.

If you’re like me, you’re happiest using both halves of your brain. You have a creative side (I’m a cartoonist and blogger) and an analytic side (hospital-based physician). It’s not easy to make a living as a cartoonist or writer, and it’s soul-sucking to work 80 hour weeks in the hospital without rest. So how do you make a living, but participate in all the things you love? You work as a traveling physician (aka locum tenens) one third of your time, and spend the other two-thirds doing the creative things you also enjoy.

“But I couldn’t survive on 1/3 of my salary,” you say. Actually, I make the equivalent of a full-time academic physiatrist salary while working ~14 weeks a year as a traveling physician. Really? Yes, really. Because when I’m filling in at a hospital with an acute need, the work hours are long, and I’m paid by the hour. It can be grueling, but it is short, and the pay is fair so morale remains high. Drawing a flat employee salary (and then often discovering that the work load requires double the time estimated by the employer) can cause a lot of unconscious resentment. But when you are paid for your time, long hours aren’t as dread-worthy. This is what attorneys have been doing from day one, so why not physicians?

“But if all physicians suddenly dropped to half or 1/3 time, wouldn’t that do irreparable damage to patient access?” you cry.  Yes, it could be catastrophic. However, if physicians stay the course and do nothing about our burnout, then the powers that be will continue tightening the vice – targeting physician reimbursement, increasing the burden of bureaucratic monitoring, pay for performance measures, and meeting “meaningless abuse” requirements for our electronic medical records systems. If there are no consequences to their actions, why would they ever stop?

I don’t think that most physicians will read this blog post and quit their jobs. I’m not worried about a sudden reduction in the physician work force. What I am offering is a suggestion for those of you who have a secret passion outside of clinical practice – a pathway that allows you to continue practicing medicine, and also enjoy cultivating your other talents. I’m hoping my advice will actually reduce the full drop out rate (if you believe the polls, up to 60% of PCPs would retire today if they had the means) to partial drop out rate (keeping those wanting to quit completely working part time).

So if there’s something you’ve always wanted to do (A non-profit endeavor? A low-paying, but rewarding job? Running a small business that can’t pay all the bills but is fun to do?) I say do it! Life is too short to get caught on the clinical treadmill, driving your spirits into the ground. You love your patients but can’t tolerate the work pace? Don’t quit altogether… you can still be a fantastic, caring, clinician in fewer hours/week and make the salary you need to maintain a reasonable lifestyle.

Please see my previous blog post to gain more insight into whether or not locum tenens might work for you.

And here’s a video of my recent thoughts about locum tenens work:

The Benefits Of Locum Tenens Work

Why Pay For Performance Measures Should Also Apply To Health Insurance Companies

In a recent post entitled, “The Joys Of Health Insurance Bureaucracy” I described how it took me (a physician) over three months to get one common prescription filled through my new health insurance plan. Of note, I have still been unable to enroll in the prescription refill mail order service that saves my insurer money and (ostensibly) enhances my convenience. The prescription benefits manager (PBM) has lost three of my physician’s prescriptions sent to them by fax, and as a next step have emailed me instructions to complete an online form so that they have permission to contact my physician directly (to confirm the year’s refills). Unfortunately, page one of the form requires you to fill in your drug name and match it to their database’s list before you can continue to page two. For reasons I can’t understand, my common drug is not in their database. Therefore, I am unable to comply with my insurer’s wish that I enroll in mail order prescription refills. This will further delay receipt of my medication – and probably increase my cost as I will be penalized for not opting into the “preferred” mail order refill process.

Now, all of this is infuriating enough on its own, but the larger concern that I have is this: How many patients are not “compliant” with their medication regimen because of problems/delays with their health insurer or PBM? Physicians are being held accountable for their patients’ medication compliance rates, even receiving lower compensation for patients who don’t reach certain goals. This is called “pay-for-performance” and it’s meant to incentivize physicians to be more aggressive with patient follow up so that people stay healthier. But all the follow up in the world isn’t going to get patient X to take their medicine each day if their health insurer or PBM makes it impossible for them to get it in the first place. And shouldn’t there be consequences for such excessive red tape? Who is holding the insurers and PBMs accountable for their inefficiencies that prevent patients from getting their medicines in a timely manner?

Pay-for-performance assumes that physicians are the only healthcare influencers in the patient compliance cycle. I’ve learned that we only play a part in helping people stay on the best path for their health. Other key players can derail our best intentions, and it’s high time that we look at the poor performance of health insurers and PBMs as they often block (with intentional bureaucracy) our patients from getting the medicine they need. While insurers save money by having patients struggle to get their prescriptions filled, doctors are payed less when patients don’t take their medicines.

Not a great time to be a doctor or a patient… or both.

The Joys Of Health Insurance Bureaucracy

From a health perspective, I am grateful to be doing well. I have only one active medical condition that is fully treated by one prescription medicine. I have been taking this medicine since I was 18 years old. I recently bought myself a personal health insurance plan (my first that was not tied to employment) and simply wanted to resume regular purchase and use of my medicine.

I was pleased to note that purchasing my medicine through the new insurance plan would save me a little bit of money (about $25/month). So I presented my card at the local pharmacy and was told that my medicine was not covered under my plan without pre-authorization from my doctor. I called my pharmacy benefits hotline and had them send a pre-auth form to my doctor. Then I asked him to fill out the form and fax it back. That was over three months ago.

When I called to inquire about the pre-auth forms, the benefits folks told me that they had no record of the fax. So I asked my doctor to send another fax form and I waited another week. When I called the benefits people, they again said that they had no record of the pre-auth documentation. They also said that I could not be transferred to the pre-auth team to figure out why it was missing (wrong fax number perhaps?) because they only speak to providers.

So out of curiosity I asked what the usual process was for obtaining a prescription medication once it has been authorized. The benefits staff didn’t know. I asked who would know and they said that only the “experts” in the pre-auth department know how medications are obtained by the member after being approved. I wondered how I’d ever figure this out if I wasn’t allowed to speak to them and I was told that I might be able to get an answer if I asked a customer care representative to request information on my behalf from the pre-auth experts. But… the pre-auth team was not in the office at the moment and I’d need to call back on Monday. (Parenthetically, the team is physically located in Pittsburgh, Pennsylvania, though I’m a member in Charleston, South Carolina.)

I asked the benefits team if they generally mail members their meds (I had heard this was the case) or if I could pick them up at my local pharmacy (my preference). They said they didn’t know, but I could call customer care on Monday.

So far, my experience with my new plan – to save $25 dollars/month on one prescription – has cost me 3 months and 1 week of waiting time, two form completion episodes with my doctor, discussions with several pharmacy benefits reps in a state far away from where I live, denial of communication with the only people who know what’s potentially holding up my prescription approval, and about a half hour of completely unhelpful discussion of basic prescription drug purchasing processes that staff at the drug benefits company themselves don’t understand.

And I’m healthy, I’m a healthcare provider who knows how to navigate the system, and I only need one prescription. What do sick people do? (I know, it’s awful out there.)

Life was much simpler when I paid for my medication out-of-pocket without an insurance middle man.  I have often wondered if health insurance bureaucracy is purposefully designed to wear patients down to the point where they’ll just pay for things themselves rather than experience the pain associated with getting an insurance company to cover their portion of the cost. (The only other explanation is that health insurance company ineptitude comes from being administrative behemoths with too many moving parts and processes).  It’s probably a mix of the two. Or maybe the latter supports the former so there’s no real incentive to pursue true efficiency.

But one thing I did notice – the insurance company was incredibly efficient at figuring out how to direct debit my premiums within 24 hours of signing up for the plan, and have increased my premium once already – by about $25 a month.

You can’t win, my friends.

If you’re healthy, get yourself a high deductible plan, pay as little in premiums as possible, and sock away some money in case of a catastrophic event. Pay cash for your primary care, and do whatever you can to stay healthy and out of the hospital. That’s my plan and I’m sticking to it.


Update: My medicine was finally approved/authorized, but I was informed that my doctor would need to send a new Rx form to them before I could receive my prescription. The Rx needed to be on their company’s form, so they had to fax him the request first. I asked how I would pay for the prescription and where I could pick it up and was informed that I’d save about 15% if I agreed to have the medicine mailed to my home (but delivery would take 2 extra weeks).

So I agreed to have it mailed to my home and offered to give them my credit card. They said I should call back with it once my doctor’s Rx had been received. I asked them how I would know when that had occurred. They said that they couldn’t call me to tell me when the Rx had arrived because I had selected “text messaging” as my preferred method of contact, and they don’t inform members of Rx form receipt via text messaging. So I agreed to switch my preference to calls (instead of text), and now I’ll probably get automated prescription refill information in the form of incoming calls on my personal work phone from now till I die. That’s if they don’t sell my phone number to telemarketers in the mean time.

And how annoying is it for my doctor to have sent out two faxes and one new Rx form for ONE prescription (not to mention reading the email explanations from me regarding correct pharmacy benefits plan form usage)? He was uncompensated for his time in this matter…

Do We Really Need Another Branch Of Government To Enforce Medical Informed Consent?

Health Leaders Media recently published an article about “the latest idea in healthcare: the informed shared medical decision.”  While this “latest idea” is actually as old as the Hippocratic Oath, the notion that we need to create an extra layer of bureaucracy to enforce it is even more ridiculous. The author argues that physicians and surgeons are recommending too many procedures for their patients, without offering them full disclosure about their non-procedural options. This trend can be easily solved, she says, by blocking patient access to surgical consultants:

“The surgeon isn’t part of the process. Instead, patients would learn from experts—perhaps hired by the health system or the payers—whether they meet indications for the procedure or whether there are feasible alternatives.”

So surgeons familiar with the nuances of an individual’s case, and who perform the procedure themselves, are not to be consulted during the risk/benefit analysis phase of a “shared” decision. Instead, the “real experts” – people hired by insurance companies or the government – should provide information to the patient.

I understand that surgeons and interventionalists have potential financial incentives to perform procedures, but in my experience the fear of complications, poor outcomes, or patient harm is enough to prevent most doctors from performing unnecessary invasive therapies. Not to mention that many of us actually want to do the right thing, and have more than enough patients who clearly qualify for procedures than to try to pressure those who don’t need them into having them done.

And if you think that “experts hired by a health insurance company or government agency” will be more objective in their recommendations, then you’re seriously out of touch. Incentives to block and deny treatments for enhanced profit margins – or to curtail government spending – are stronger than a surgeons’ need to line her pockets. When you take the human element out of shared decision-making, then you lose accountability – people become numbers, and procedures are a cost center. Patients should have the right to look their provider in the eye and receive an explanation as to what their options are, and the risks and benefits of each choice.

I believe in a ground up, not a top down, approach to reducing unnecessary testing and treatment. Physicians and their professional organizations should be actively involved in promoting evidence-based practices that benefit patients and engage them in informed decision making. Such organizations already exist, and I’d like to see their role expand.

The last thing we need is another bureaucratic layer inserted in the physician-patient relationship. Let’s hold each other accountable for doing the right thing, and let the insurance company and government “experts” take on more meaningful jobs in clinical care giving.

Should Primary Care Be Abandoned?

In his last post, DrRich pointed out to his PCP friends that their chosen profession of primary care medicine is dead and buried – with an official obituary and everything – and that it is pointless for PCPs to waste their time worrying about “secret shoppers” and other petty annoyances.

It is time for you PCPs to abandon “primary care” altogether. It is time to move on.

Walking away from primary care should not be a loss, because actually, primary care has long since abandoned you. Whatever “primary care” may have once been, it has now been reduced to strict adherence to “guidelines,” 7.5 minutes per patient “encounter,” placing chits on various “Pay for Performance” checklists, striving to induce high-and-mighty healthcare bureaucrats (who wouldn’t know a sphygmomanometer from a sphincter) to smile benignly at your humble compliance with their dictates, and most recently, competing for business with nurses.

This is not really primary care medicine. It’s not medicine at all. It’s something else. But whatever it is, it’s what has now been designated by law as “primary care,” and anyone the government unleashes to do it (whether doctors, nurses, or high-school graduates with a checklist of questions) now are all officially Primary Care Practitioners.

What generalist physicians (heretofore known as primary care physicians) need to realize is that “primary care” has been dumbed-down to the point where abandoning it is no loss; indeed, it ought to be liberating to walk away from it.

The beauty is that Read more »

*This blog post was originally published at The Covert Rationing Blog*

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