Author: MJ

3/5/2014

The new ICD-10 is out–and over a 1000 pages long. This is the book we doctors are forced to follow when billing for our services. It is a list of diagnoses and conditions we must adhere to when trying to justify our importance to patients and more critically to their insurers so that we can be paid. It weighs in at several pounds but its value is inversely proportional to its size: it does nothing to improve patient care, and less than nothing to keep down costs–in fact because it takes an inordinate amount of time to use this garbage doctors have less time to actually take care of patients and are incentivized to extract as much reimbursement from better coding from this time-consuming process as they can–which inevitably leads to higher medical costs. Duh.

Just one more example of how unecessarily complex our health care system is–could we please just take care of patients?

Let me give you an example. When I admit a patient to the hospital with pneumonia I am not allowed to simply write a diagnosis of pneumonia, the liklihood of how and where it was acquired denoting an assessment of the risk and severity of it, and also of the indicated treatment. To be paid the best level (which matters very much to my employer if not to me) I have to write what kind of pneumonia it is, for instance, due to gram positive or gram negative bacteria. I have to write this even though I don’t know, and will never know, what kind of bacteria it is. This is because we don’t sample lungs for bacteria – it’s dangerous- too dangerous to risk. So we guess. No matter what hoity-toity medical center you go to – we always guess at the cause of pneumonia. In fact the pneumonia may not be bacterial at all – it may be viral- and which is even less easy to identify than bacterial. But still we are forced to adhere to this guessing game of what specific kind it is to be paid. Stupid, just stupid because it doesn’t serve the patient, it doesn’t serve the doctor. It just serves the insurance company. Bravo American health care.

3/28/2015

There is no doubt that the business of medicine has changed in the thirty years I’ve been in practice, just as it did in the thirty years before that, and the thirty years before that. What hasn’t changed is the ability, and the privilege, of a physician to deliver excellent care to his or her patients, with compassion, dignity and respect. In fact, over time these qualities have become even more important to my patients, for whom such care stands out more than ever.

National health care does not frighten me; I believe dumping the insurers is the only way to place the patient and the primary care physician back at the center of health care. The insurance industry, after all, is not in business to serve the patient (nor us), but the stockholder. Every dollar in the shareholder’s pocket is another dollar taken at the expense of the patient’s health. I have spent plenty of time arguing with private insurers on the phone to get my patients what they need, something I have never had to do with Medicare. Further, the data are clear on two points about Medicare: it is the most cost-effective and quality-driven insurer out there; it could be even more so but for lobbyists and the politicians beholden to them )which is almost all of them).

“Cookbook medicine” has been the bogey man since I was in training, so I am rather inclined to roll my eyes at the same paranoia spouted today. There is too much to know for any of us docs, I don’t care how dedicated you are, to keep up with everything every day. Particularly in family or internal medicine. While I certainly do practice medicine on individuals, I take very seriously the data that helps us identify what works and what doesn’t, what’s harmful and what is not. Algorithms and reminders help to make our care idiot-proof, and allows us to spend more time with our patients.

Lastly, I work with a lot of new graduates in my current field of hospital medicine (I had my own private practice for > 20 years), and find them to be just as dedicated to patients as anyone I knew at OSU 30 yrs ago. About the only difference in the past 15 years is the zeal with which most of the new grads, out- and in-patient oriented, get consults. This is the place where I think we need to get back on track with education: our patients do not need more specialists—they need fewer. They don’t need more testing, by and large they need less, and better directed evaluation and treatment.

My advice to new docs is to go out there and be the best doc you can be with each patient every day. Find joy in your work—if you do that, no change in health care policy can take it away. Know when to play by the rules and when it’s worth trying to break them. Stand up for what you believe in, not just on media sites, but in conversations—let people know what you know. Learn the data on health care policy and become an advocate for all your patients, not just those who can pay you (you may want to check out PNHP.org if you’re looking for data). Good luck, and may the force be with you…!