Archive for July, 2009

DMV Healthcare

July 29, 2009

“Have you been to the DMV lately?” This is a popular starting point used by folks attempting to frighten us away from health care reform, intending to scare us by suggesting if health care reform takes place we will sit in waiting rooms endlessly just to be treated as numbers by inefficient government bureaucrats. It is a powerful image. Although we all feel bad about the number of uninsured Americans out there, those of us with insurance don’t want our medical care to go the way of the DMV. Oh no, of course we do not!

Whenever I hear a pundit or politician make this statement about the DMV as the stand out example of government bureaucracy I wonder what their experience with the medical system has been lately and how that might compare to the DMV. I wish they would please tell us where they are getting such highly personal, efficient medical care while using their insurance. I want to make appointments for all my family members. Right now, I would take the DMV over the doctor’s office any day.

I just reached a milestone birthday last week so I actually had the opportunity to visit my DMV. I can honestly answer that, yes, I have been to the DMV lately and it was reasonably pleasant. I waited in a line of about three people to check in, sat in a chair in the waiting room for less than 10 minutes, took the eye test given by a very pleasant woman who was able to quickly pull up my correct demographic information from her computer, review my designation as an organ donor and register me to vote if I wished. Then I had a picture taken quickly and was out the door in less than thirty minutes. I was told that there is an option to make an appointment that could have made the experience even quicker.

Also last week, just in time for my birthday, my older daughter was ill with a fever and sore throat. Because she is prone to strep and had a high fever for a few days I thought it was a good idea to have her see the doctor to get a strep test. As a family physician myself I have a good sense of when it is finally time to see the doctor. Her pediatrician’s office has walk-in hours but they are across town and usually very busy, so we decided to take her to an urgent care center nearby in hopes that it might be quicker. First there were multiple forms to fill out so she could be entered into their computer system. This took several minutes work for us and the receptionist. Their computer system does not link to any other medical offices and therefore none of her records are accessible to anyone else. Then insurance information must be filled out so it can be entered for billing purposes. Another staff member takes several minutes to reach the insurance company to verify our insurance and perhaps get preauthorization for the visit.

After over an hour wait and a 75 dollar copay my daughter was seen for less than five minutes by a primary care doctor. The strep test was negative but he offered us antibiotics anyway. I’m sure he knew this wasn’t medically indicated but felt bad about the long wait. He also knew that he could get out of the room more quickly if he just wrote a prescription rather than attempt to explain why viruses aren’t killed by antibiotics. I’m sure he could use any possible extra time between the 5 to 10 minute appointments to write his note about the visit. The documentation must be fairly extensive to ensure payment. He likely spent more time documenting than he spent in the room with her.

If the long wait, high copay, and poor medical advice weren’t frustrating enough I know that the most inefficient part of the visit is still yet to come. After we were long gone from the office a staff member must file a claim with our (private) insurance company in hopes that they may be paid something else above and beyond our large copay. The insurance company may take several days or weeks to respond and may simply deny the claim for a coding error by the provider, for a preexisting condition, or just because they deemed the visit unnecessary. No further explanation of the denial is required. Copies of visit notes may need to be mailed to the company for review to ensure the provider did check the right boxes and use the appropriate code to the second decimal place. Supporting letters by patients and medical providers may need to be written but further payment from the insurance company is certainly not guaranteed. The urgent care provider’s office might give up on receiving anything from the insurance company because they got a seventy five dollar co pay from us already and further hassle is just not worth it. However, a typical primary care office that signs a contract to be “in network” with insurance companies is not allowed to charge higher copays. They are left to fight for every dollar of insurance reimbursement or shift the unpaid amount to the patient. I have worked in small primary care offices where the owners had to take out personal loans to make payroll because they had not received the insurance reimbursements they expected.

I know these insurance games from all sides. I have received denials for the care I’ve provided to patients as well as denials for care provided to my family members by their own doctors. My younger daughter was hospitalized for dehydration last fall and soon afterward we received a denial of payment for the hospital stay because it was coded as an “admission” instead of an “observation”. Eventually we had this corrected but the time, energy and frustration it caused was enormous and if we hadn’t had the guts and knowledge to fight their decision we could have been out over three thousand dollars.

My family and our experiences with the health care system are pretty typical. If you have had the pleasure of seeing a doctor lately I imagine you could tell you own similar story of some inefficiency, bureaucracy or impersonal care. Unfortunately it has become the accepted norm for medical care these days. It is not uncommon for a full-time primary care doctor to have upwards of 3,000 patients. It is impossible to know all of these individuals well and to truly listen to their concerns without feeling distracted and overwhelmed. Monetary incentives are given to see patients as quickly as possible. Most primary care docs I know run from exam room to exam room simply trying to keep up, not forget something big, kill anyone or get sued. There is no incentive to limit testing or procedures since the more a physician does, regardless of quality or outcome, the better he’s reimbursed. In addition, ordering an xray or a lab test or writing for an expensive prescription is the easiest way to end a visit quickly. Talking to patients and explaining why certain things aren’t necessary is difficult, timely and not reimbursable. Primary care physicians who refuse to compromise quality are being driven out of business or forced to change career paths.

According to a recent New England Journal of Medicine survey the average Medicare patient saw a total of seven doctors — two primary care physicians and five specialists — in a given year. Without a system of electronic medical records that connect to each other these doctors don’t communicate and the care is horribly fragmented. There is a huge amount of duplicated care and inefficiency which leads to increased costs and medical errors. To obtain old records on patients you must send a signed request to the other physician’s office (who will often charge the patient for this) then wait for faxed or mailed copies of old records to arrive. Many of these records will never be located and might take over thirty days or more to show up. Waiting for records that may or may not arrive is often too timely so tests are reordered and work ups of medical problems get repeated. Imagine if our local police offices or court systems could not connect to other districts, state or federal records to screen for prior offenses or outstanding warrants and had to wait 30 days or more to find out information. This is the current state of medical records in this country.

A recent survey published by the Archives of Internal Medicine in June of this year showed that the failure of doctors and medical facilities to follow-up and give people test results is “relatively common,” even when the results are abnormal and potentially troublesome, and affects one of every 14 tests. An acquaintance of mine recently saw a doctor for headaches and was sent for an MRI and a cardiac testing. She was not given a follow up appointment and was not contacted by the doctor again so she assumed all was well. A few months later she saw a gynecologist and they were considering an elective surgery. The gyn doctor said he wasn’t sure she was a good surgical candidate given her heart problem. “What heart problem?” she said. The first doctor failed to inform her about the abnormal heart test. She was just lucky the two doctors worked in the same hospital and the gynecologist chose to look at her cardiac test results. In most situations two doctors can’t access each others’ notes or any results of tests another doctor ordered.

After several years of training and working in outpatient primary care I recently left my practice to work in a hospital setting. I am not alone. Nearly half the respondents in a Physicians Foundation survey of U.S. primary care physicians said that they would seriously consider getting out of the primary care medical business within the next three years. Currently less than two percent of medical students choose primary care fields. I miss my patients but I do not miss debating the correct code for my outpatient visits, having to see people in ten minutes time and being paid only for what insurance bureaucrats deemed necessary. Even if you desperately want to do a good job it seems the system is stacked against you. I loved taking care of my own patients but the system is so broken that there is no more doctor/patient relationship there are only doctor/insurance company/patient relationships.

So, yes, I’ve been to the DMV lately. It was efficient with centralized records and pleasant people. I knew exactly how much it was going to cost me. I did not have to wait terribly long. I received the results of my tests right away and they won’t be contacting me to say they have decided to “deny” my license and need me to pay more. Perhaps the better question to ask in considering health care reform is “Have you been to see a doctor lately”?