By Steve Simmons, M.D.
Last week, my partner wrote about a game played between doctors and insurance companies. After reading his post, I recalled the time I first learned that modern medicine was something altogether different than what I had expected. I began my career as a primary care physician in 1996. Fresh out of residency, I was optimistic, naïve, and unaware that a very real game was being played. As time passed, I became a player in this game, but slowly realized that something of value was lost by my patients trying to translate their insurance coverage into health care. Likewise, the struggle to interpret the healthcare system for my patients caused me the same frustration that has led many doctors to leave primary care today.
Early in my practice I was eager to begin my career, relieved that my training was over. However, my training in the game had just begun. To my consternation, insurance company demands soon usurped the time I spent on everyday clinical problems. Often, I’d find my office stacked deep with charts waiting for my review and approval, a consequence of an insurance company changing a drug formulary involving dozens of patients. It seemed a day couldn’t pass without administrative staff requiring an explanation for a treatment I had already recommended so they could arrange pre-authorization.
Insurance coding was not taught in medical school or residency, yet it’s the primary language used to communicate with insurance companies. I needed to learn this ‘skill’ on the fly, using a code book to translate each medical diagnosis into a five digit number, with an additional number serving as a cipher to explain the type of work I had done for a patient. This code book does not contain some diagnoses and many of its diagnostic codes inaccurately describe medical conditions, causing inevitable mistakes that led to non-payment.
In Money-Driven Medicine, Maggie Mahar describes the 1990s as the time of HMOs, when reimbursement became paradoxical. Then, an HMO gave a primary care physician $10 a month per patient, regardless of what we did or did not do for that patient. If we saw our patient in the office we kept the co-pay, but nothing else was reimbursed. If we admitted a patient to the hospital, we received $0, resulting in lost office time, lost opportunities to see other patients, and lost revenue.
Some wonder why primary care physicians don’t go to the hospital anymore. Here’s why: They can’t afford to leave the office. They must stay put and move people through their office, which resembles an assembly line, if they want to stay financially afloat. When I observed that the only way to earn money caring for someone in an HMO was to never see them, my partner looked at an older colleague, smiled, and said, “He finally got it.”
Navigating nonsensical limits and rules became infuriating. One young man, brought to me by his tearful father, was hearing voices. Soon into my exam I realized he suffered from a mental illness. His plan stipulated the patient only could initiate mental health benefits, not a family member. However, the voice was telling him not to call; yet he agreed to see a psychiatrist if someone else would call. I spent well over an hour pre-authorizing his mental health benefit.
Examples include physical illnesses too. I diagnosed a cancer in a woman whose HMO offered only one specialist; someone I would not have consulted. With no choice, I referred her. Days later, she returned in tears stating that she would never see someone who knew less about her problem than she did. I agreed and spent the rest of the afternoon wrangling with her insurer to get a different specialist approved.
When I moved to the Washington DC area, I left primary care. For ten years I worked in urgent care, earning a steady paycheck while avoiding overhead expenses. I could go home without being followed by the constant frustration of trying to untangle impossible knots. Yet, I missed the opportunity to build relationships with my patients and was not using the skills I had developed. When given the chance to work in primary care again without the endless hassles, I seized it. Today, I am gratified to have returned to my calling. It is more rewarding to practice medicine outside of the current insurance model and I remain thankful to my partner at doctokr Family Medicine for the opportunity to do so.
Today, much is lost between patients and doctors. If physicians and patients could connect without so many distractions, primary care would, again, resemble a calling more than a job and the primary care shortage would not be reaching a crisis point. Too much time and effort is spent on a game controlled by endless rules and regulations; time that could be focused on the patient — who should be the true focus, after all.
Until next week, I remain yours in primary care,
Steve Simmons, MD