By Doctor Mark Sklar, assistant professor of medicine at
the Georgetown University Medical Center and at the George Washington
University Medical Center.
* * *
* * *
It has been four years since the passage of the
Affordable Care Act [ObamaCare] so I thought it may be useful to provide the
perspective of a physician providing daily medical care. I am an
endocrinologist in Washington, D.C., and have been in solo private practice for
17 years after seven years at an academic institution. Since 1990, the practice
of medicine has changed significantly, seldom for the better.
In the 1990s insurance companies developed managed-care
plans that greatly increased their profits at the expense of the physician.
With the Affordable Care Act, we are seeing new groups profiting from changes
to the health-care system.
* YEP! THAT'S WHY THE CRONY CAPITALIST INSURANCE INDUSTRY
(AND EVEN BIG PHARMA) DIDN'T FIGHT OBAMACARE AS THEY SHOULD HAVE! INSTEAD, THEY ACTUALLY CONSPIRED WITH THE ADMINISTRATION!
Entrepreneurs and hospital executives...
* WITH BONUSES AND STOCK AWARDS THAT DEPEND UPON
SHORT-TERM PROFIT GROWTH AND TO HELL WITH THE FUTURE!
...are capitalizing on organizing physicians into groups
called Accountable Care Organizations from which they will take a very
substantial percentage of collected income.
* YEP...
Now that physicians are being required to use electronic
medical records, the companies that develop them are harvesting money from
physicians' practices and from hospitals.
The push to use electronic medical records has had more
than financial costs. Although it is convenient to have patient records
accessible on the Internet, the data processing involved has been extremely
time consuming — a sentiment echoed by most of my colleagues. To save time, I
was advised by a consultant to enter data into the electronic record during the
office visit. When I tried this I found that typing in the data was disruptive
to the patient visit. My eyes were focused on the keyboard and the lack of
direct contact kept patients from opening up and discussing their medical and
personal problems. I soon returned to my old method of dictating notes and
pasting a print-out of the dictation into the electronic record.
Yet...
* YET...
...to avoid future financial penalties from Medicare, I
must demonstrate "meaningful use" of the electronic record. This
involves documenting that I covered a checklist of items during the office
visit, so I spend 90 minutes each day entering mostly meaningless data. This is
time better spent calling patients to answer questions or keeping updated with
the medical literature.
* FOLKS... PART OF ME WANTS TO SAY "GOOD!" WHY?
BECAUSE DOCTORS - DOCTORS UNITED - COULD HAVE STOPPED OBAMACARE IN ITS TRACKS!
THEY COULD HAVE LOBBIED THEIR POLITICIAN PATIENTS! THEY COULD HAVE LOBBIED THE
FRIENDS AND RELATIVES OF POLITICIANS! HELL... THEY COULD HAVE - AND SHOULD HAVE
- LOBBIED THE AMERICAN PEOPLE... ONE PATIENT AT A TIME... DURING EACH AND EVERY
VISIT. INSTEAD... THEY LARGELY KEPT THEIR OWN COUNSEL AND ALLOWED THE OBAMACARE
DISCUSSION TO BE A POLITICAL ONE!
If electronic records ever allow physicians to obtain
data from previous laboratory and imaging testing, it will improve costs and
patient care. So far, however, the data in electronic records — like paper
charts — can't be shared unless physicians work in the same health-care system.
* DID YOU KNOW THIS, FOLKS?
My practice quickly adopted the new Medicare requirements
for electronically prescribing medications. Yet patients often do not want
their prescription sent electronically. They want a physical copy — either
because they don't trust the Internet or because they don't need to fill the
prescription immediately. If I don't electronically prescribe for a certain
number of Medicare patients, I am penalized with a decrease in reimbursement
that can rise to a maximum of 5%.
* I MYSELF HAVE BEEN CAUGHT UP SEVERAL TIMES IN THIS
DISASTER! ELECTRONIC PRESCRIPTIONS HAVEN'T GONE THROUGH... OR THEY'VE GONE
THROUGH TOO EARLY... OR THEY'VE BEEN FILLED AT THE WRONG COST OR IN THE WRONG
QUANTITY...
(*SIGH*)
Patients should have a choice in how their prescriptions
are delivered, and physicians shouldn't be penalized for how the patients
choose.
To prevent physicians from prescribing more costly
medications and tests on patients, insurers are increasingly requiring
physicians to obtain pre-authorizations. This involves calling a telephone
number, often being rerouted several times and then waiting on hold for a
representative. The process is demeaning and can take 30-45 minutes. Rather
than having physicians pre-authorize expensive medications, the outrageous
costs of many non-generic medications must be addressed. I understand that
pharmaceutical companies need to make profits to cover investments in drug
development. However, they should have some compassion for their customers.
* IT'S NOT THE PHARMACEUTICAL COMPANIES! IT'S THE FDA!
IT'S THE SHORT LENGTH OF PATENT PROTECTION! IT'S THE ECONOMIC REALITY OF
OPERATING WITHIN THE CONSTRAINTS OF A GOVERNMENT REGULATORY AND TAX STRAIGHT
JACKET!
To avoid Medicare penalties, I also must participate in
the Physician Quality Reporting System program. Initially, this involved
choosing three codes during the patient visit to reflect quality of care, such
as blood pressure or blood-sugar control, and reporting them to Medicare. In
2015, the requirement will increase to nine codes.
Coming down the pike, but thankfully postponed from the
October 2014 deadline, is something called ICD-10. This is a newer system that
will contain about 70,000 medical diagnostic codes used for billing insurance.
The present ICD-9 system has about 15,000 codes. The Physician Quality
Reporting System and ICD-10 requirements are intended to benefit population
research, but the effect is to turn physicians into adjuncts of the Census
Bureau who spend time searching for codes — and to further decrease the amount
of direct contact with patients.
The practice of medicine in the current environment is
unsustainable.
* READ... THAT... AGAIN... FOLKS...
The practice of medicine in the current environment is
unsustainable.
(*PURSED LIPS)
The multiple bureaucratic distractions in my day consume
so much time that I have to give up what little personal time I have in the
morning, evening and on weekends if I want to continue to provide excellent
care during office hours.
If high-quality medical care is the goal, the
bureaucracies need to be tamed. Our government and insurance companies
understandably want to measure outcomes of health-care dollars spent. However,
if the health-care system rewards data entry, that is what it will get — the
quality of care seems an afterthought.
* YEP...
* THINK ENCROACHING CREDENTIALISM IN EDUCATION AND THE
PROFESSIONS. ALL IT DOES IS "RE-NORM" THE LEVEL OF (IN)COMPETENCE AT AN
ARTIFICIALLY "HIGHER" LEVEL.
The patient should be the arbiter of the physician's
quality of care. Contrary to what our government may believe, the average
American has the intellectual capacity to judge. To give people more control of
their medical choices, we should move away from third-party payment.
* YES! YES! YES!
It may be more prudent to offer the public a
high-deductible insurance plan with a tax-deductible medical savings account
that people could use until the insurance deductible is reached. Members of the
public thus would be spending their own health-care dollars and have an
incentive to shop around for better value. This would encourage competition
among providers and ultimately lower health-care costs.
* YES! THIS IS WHAT I'VE ALWAYS SUPPORTED!
By contrast, the Affordable Care Act's plans for
establishing "medical homes" — a team-based health-care delivery
model — and accountability-care organizations will only add more bureaucracy
and enrich the consultants and companies organizing these entities.
* O*B*V*I*O*U*S*L*Y
To improve quality, we need to unchain health-care
providers from the bureaucracies that are strangling them fiscally and
temporally. We can better control medical costs if we strengthen physicians'
relationships with their patients rather than with their computers.
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