February 11th, 2009 by Dr. Val Jones in Primary Care Wednesdays
4 Comments »
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
January 28th, 2009 by Dr. Val Jones in Opinion, Primary Care Wednesdays
No Comments »
By Steve Simmons, M.D.
When I graduated from the University of Tennessee’s Medical School sixteen years ago, my last act as a student was to take the Oath of Hippocrates with my classmates and 98% of the other medical students graduating in the United States that year. This oath still resonates within me today and connects me to all physicians reaching back over 2,500 years to the time of Hippocrates.
Implicit in an oath is the understanding that the profession chosen will require more sacrifice than the average vocation, that the occupation’s rewards should be more than a paycheck, and that a paycheck would impart less value than the enrichment gained from nobly serving others. The high standard which society holds physicians to is still accurately described by the Hippocratic Oath. Regardless of what changes seep into our profession from outside influences, doctors will always be held to the ideals written in the Hippocratic Oath.
When I was a young medical student, the hope that becoming a physician would bring value and meaning to my life was more rewarding than thoughts of job security or financial stability. This helped propel me and my classmates through many long nights of study. One sentiment oft-heard in my medical school, and I suspect many medical schools today, was that no one would put up with ‘this’ just for money–usually stated prior to a re-doubling of the effort to get past a particularly challenging task. Painful physical effort often was required, such as waking at 3AM to make hospital rounds, or spending 24-hour long shifts stealing naps and bathroom breaks, sometimes even working over 100 hours a week during demanding rotations. Steven Miles, a physician bioethicist, wrote, “At some level, physicians recognize that a personal revelation of moral commitments is necessary to the practice of medicine.”
I would proffer that few students would endure the sacrifices necessary to graduate without understanding this point.
In Paul Starr’s 1982 book, The Social Transformation of American Medicine, he stated that in the future the goal of the health industry would not be better health, but rather the rate of return on investments. This unfortunately has come to pass. Arguably, medicine now is controlled by CEOs and other executives in the health industry — individuals who are not expected to take an oath. Physicians, remaining loyal to the Oath, are an unwitting weak and junior partner in today’s health care industry. Worse, doctors are now employees, often seen as interchangeable parts with one doctor considered no different than another. Third party providers in the health care industry fail to place any value on the personal interactions between doctor and patient. It may be better that the CEOs of health insurance companies are not required to take an oath, since many are on record, admitting loyalty to the share-holder alone with profits their first consideration.
Before the Great Depression, only 24% of the U.S. medical school graduates were given the Oath at graduation. Does this suggest they were less ethical? I don’t think so. I believe the increased use of the Oath demonstrates a growing awareness on the part of our educators that business has taken a controlling interest in the practice of medicine and that their graduates should be reminded that society still expects them to deliver on the noble promises of the past. Hippocrates’ Oath helped pry medicine away from superstition and the controlling interests of Greece’s priesthood in the fifth century B.C. Hippocrates plotted a course towards science using inductive reasoning while his Oath anchored his fledgling art on moral truths unassailable even today. I suspect he would see little difference between those profiting within the priesthood of his day and those monopolizing healthcare today. He would find familiarity in those putting forth their difficult-to-decode rules of reimbursement, recognizing these rules as intentionally confusing, pejorative, and detrimental to patients and physicians alike while profiting those few in control.
How would Hippocrates advise today’s students and physicians when shown how monetary realities have finally subsumed us all? He might remind us that money was not our motivation in pursuing this career and show us how a return to the reverence for our art, embodied by the Oath, could become a modern conveyance to the ideals of the past. By regaining our reverence for what motivated and guided us through medical school and residency we should find ample courage to do whatever is necessary. Much is needed to wrest control of today’s broken healthcare system from those making huge profits…. and an oath can remind us why it is important.
Until next time, I remain yours in primary care,
Steve Simmons, MD
January 14th, 2009 by Dr. Val Jones in Primary Care Wednesdays
No Comments »
By Steve Simmons, M.D.
Gordian Knot: 1: an intricate problem ; especially : a problem insoluble in its own terms —often used in the phrase cut the Gordian knot 2: a knot tied by Gordius, king of Phrygia, held to be capable of being untied only by the future ruler of Asia, and cut by Alexander the Great with his sword
Generations ago, the American Medical Association’s (AMA) Code of Ethics stipulated that allowing a third party to profit from a physician’s labor was unethical. This tenet resides in a time when house calls were common place; when trust and respect helped forge an immutable bond between doctor and patient; and when it would have been unthinkable to allow anyone other than the doctor, family, or patient to have a role within the doctor-patient relationship.
The landscape of today’s healthcare system and its delivery methods make the authors of the AMA’s forgotten code look prescient. Insurance companies, controlling the purse strings, have become an unwelcome partner within the doctor-patient relationship, frequently dictating what can and can’t be done, and are reaping a healthy profit from their oversight. Obscene salaries and large bonuses are awarded to the CEOs of these companies for keeping as much money as they can from those providing health services, with the CEO United Healthcare being reported as receiving a $324 million paycheck during a five year period. Thus, short-term business strategies are given priority, often at the expense of patients’ long-term medical goals, creating a Gordian knot so entwined that no one – patients, doctors, insurance providers, or government regulators – can see a way to unravel it.
A result of so much money being skimmed off the top is that no one seems to be getting what they need, let alone want. Patients long for more time to discuss problems with their doctor and wish it were easier to get an appointment. Yet physicians are unable to receive adequate reimbursement from insurance companies for their services, and if they do get reimbursement, it’s after months of waiting and often at the high expense of having a posse of back office staff needed to negotiate these payments. These physicians therefore are forced to overload their schedule and rapidly move patients through their office if they are to earn their typical $150,000 per year, pay off medical school debt, and afford the salaries of their office employees. Finally, government agencies, looking for the elusive loop to tug on, ultimately burden physicians further with a myriad of onerous rules and regulations.
Read more »
December 31st, 2008 by Dr. Val Jones in Health Tips, Opinion, Primary Care Wednesdays
No Comments »
By Steve Simmons, MD
What do New Year’s Resolutions tell us about ourselves? Will they cast light on our hopes for the coming years or embody regrets best left in the year past? Resolutions tell us about our hopes, about who we want to be, and if made for the right reasons can lead us to the person we wish to be tomorrow. A positive approach utilizing the support of family, friends, and caregivers will help us follow through with our resolutions and improve our chances for success.
For the last two years, resolutions to stop smoking, drinking, or overeating, have ranked only ninth on the New Year’s Resolutions list, while getting out of debt, losing weight, or developing a healthy habit are the top three. If you find this surprising, you are in the company of many physicians. Yet this demonstrates the positive approach preferred by a majority making a New Year’s resolution. For each person making a resolution to stop or decrease a bad behavior, five choose to increase or start a good behavior, instead. We can learn from this and maintain a positive focus when considering and following through on a resolution. Keep in mind that only 40% find success on the first try and 17% of us need six tries to ultimately keep a resolution.
Avoid making hasty New Year’s resolutions based on absolute statements, which all too often meet with failure at the outset. We recommend an approach based on The Stages-of-Change-Model, developed from studying successful ex-smokers. For 30 years, primary care doctors have used this model to help their patients successfully rid themselves of a variety of bad habits. The Model’s foundation is the understanding that real change comes from within an individual.
Below, I’ve outlined the five typical stages a person progresses through in changing a behavior, using the example of a smoker:
1. Stage One/Pre-contemplative: This is before a smoker has thought about stopping.
2. Stage Two/Contemplative: A smoker considers stopping smoking.
3. Stage Three/Preparation: The smoker seeks help, buys nicotine gum, etc.
4. Stage Four/Action: The smoker stops smoking.
5. Stage Five/Maintenance and Relapse Prevention: Still not smoking, but if our smoker smokes again, keeps trying to stop, learning from mistakes.
The family and friends of a resolution maker are an intrinsic part of success and should avoid a negative approach. Instead, help them move through the stages, advancing when ready at their own pace. The following exchange is typical of an office visit where a spouse’s frustration spills over, finding release:
“Dr. Simmons, Tell John to stop smoking!” John’s wife demands of me.
“Mr. Smith, you really should stop smoking,” I request of John.
“Well Doc, I don’t want to and that’s not why I’m here,” John says, pushing his Marlboros deeper into his shirt-pocket, clearly agitated with his wife and me.
“I’m sorry Mrs. Smith, John doesn’t want to stop, perhaps I could hit him over his head, knock some sense into him?”
Once negative energy has been interjected between me and my patient, I struggle to find an appropriate response. Should I use humor to redirect? I have rarely seen someone stop a bad habit after being berated. I would prefer a chance to help him think about smoking and how it’s affecting his health. Does he know that smoking is making his cough worse? Has he been thinking about stopping lately? Nagging seems to be more about our own frustration than a desire to help and should be avoided since the effect is usually the opposite intended.
A resolution can show the path to a happier and healthier life. If you or someone close to you is planning to make a New Year’s resolution, just start slow, stay positive, have a strong support network….and one more thing: Resolve to stay Resolved.
December 10th, 2008 by Dr. Val Jones in Primary Care Wednesdays
1 Comment »
By Steve Simmons, M.D.
 |
|
Steve Simmons, M.D.
|
In the early 70s Marcus Welby MD, embodied the expectations of patients and the hopes of doctors seeking to emulate his bedside manner. Sadly, when we look at medicine today, patients and doctors alike are left wondering what happened to Welby’s style of patient-focused medicine. Much has changed in healthcare during the nearly 40 years since the show first aired. Patients are more informed and expect to be included when clinical decisions are made. Insurance companies and government bureaucracies have wrested control of the patients from their doctors. Doctors must now focus on business and mind-numbing paperwork to the detriment of their medical knowledge and patients. Runaway costs and an impersonal health care system dominate the landscape of the early 21st century.
The interests of the patient should be paramount and the doctor-patient relationship sacrosanct; however, by inviting a third party into this relationship the interests of the patient are frequently subverted. The office meetings of the past, where difficult medical cases would be discussed, have been replaced with business meetings, insurance coding seminars, and a parade of experts reminding physicians to sit during the office visit to create the impression of more time being spent with their patient. The inevitable frustration patients feel is directed towards their physician, who in turn has been saddled with his own frustration trying to merge ethical and business concerns.
Doctors are leaving primary care in droves, half planning to work less, become administrators, or retire. A survey of medical students discovered hectic clinics, burdensome paperwork, and systems that do a poor job of managing patients with chronic illness as reasons for not choosing primary care medicine. Only 2% of students plan to select general internal medicine as a career. Most students are becoming specialists, where they can make more money, glean respect, and better control their schedule. If national healthcare becomes a reality, today’s critical shortage of primary care doctors will become problematic when the uninsured start looking for a doctor.
What qualities do we want in a primary care physician and what role do we need him to play in our lives? A succession of TV doctors: Welby, Hawkeye, and now, House, share the virtues of diligence, attention to detail, and moral courage. They can help us track the evolution of our patient’s expectations over four decades. Dr. Welby’s patients willingly followed his guidance and instruction, while Dr. House’s patients live in the Information Age and have probably searched the internet before seeking his help. Unfortunately, the admiration felt for Dr. House helps demonstrate that an entire generation expects an aggressive and uncaring doctor, thinking it the norm.
In 1979, Alan Alda gave the commencement address at Columbia University Medical School, titled, “On Being a Real Doctor.” He said, “We both study the human being and we both try to offer relief–you through medicine, and I through laughter–but we both try to reduce suffering.” Few believe today’s healthcare system is focused on suffering. Third party payers are holding on to the money, controlling care, and this influences doctors. Patients like physicians have lost focus on what really matters: to ease suffering.
I sometimes imagine Dr. Welby practicing medicine today. Towards the end of his day I see him sitting behind his desk, entangled in red tape, frustrated by his inability to untie the knot binding medical and financial realities. His waiting room is full of patients, dragging the same red tape behind them.
Fortunately, if one doctor’s argument is correct and all primary care physicians are Marcus Welby, we have reason to hope. Our healthcare system is broken, but not irrevocably. Doctors and patients can stop wrestling against their constraints, turn away from their frustration, and find each other. Patients will use access to information and drive health reform forward; many are speaking up today. Doctors would do well to remember we are all patients but the onus of explaining the healthcare crisis and proposing meaningful change falls on physicians. In our practice, doctokr Family Medicine, we try to cut red tape wherever we can, striving for an open and transparent practice, placing the doctor-patient relationship central in everything we do. I believe you can find a doctor like Marcus Welby in your community and hope our posts will encourage you to try.
Until next week, I remain yours in primary care,
Dr. Steve Simmons, doctokr Family Medicine
