Last month, MedPage Today started running a series of interviews in which they ask leading doctors and clinicians ten questions about medical practice, our health-care system, and their experiences and opinions. Two of those ten provide some exceptional insights into what’s wrong with our health-care system:
1) What’s the biggest barrier to your practicing medicine today?
4) If you could change or eliminate something about the healthcare system, what would it be?
And one question provides exceptional insights into the human impacts of our systemic problems:
2) What is your most vivid memory involving a patient who could not afford to pay for healthcare (or meds or tests, etc.) and how did you respond?
This. This is what policymakers should be paying attention to if they really want to reform health care.
You all know I am not a fan of the Affordable Care Act, because it does nothing to rein in skyrocketing medical costs in this, the most expensive health-care system in the world. I believe that the single biggest hurdle to universal access is cost, and that won’t change under the ACA. Unpredictable prices from one hospital to the next; unpredictable reimbursements from insurance or Medicare or Medicaid; fee-for-service that drives up overall costs; outrageous malpractice insurance costs driven by too many frivolous malpractice suits, paired with secretive medical review boards that too often allow truly dangerous doctors to keep practicing; out-of-reach prices for some medications, and too little research and development where there is little financial incentive.
Many of the doctors interviewed in this series seem to agree, and have a lot more to say besides. Their comments barely scratch the surface, yet are a gold mine of information about what really needs to be reformed. Policymakers, take note of this sampling:
… insurance companies trying to save money or make sure I don’t waste their money…. Then Medicare and insurance companies. … They do this by making me write absurd notes, which I have; information no one wants. … Every time I want to give the drug, I have to figure out if someone will pay for it, and I have to try and figure out whether Medicare — if it’s a Medicare patient — will come back in 5 years and try and take the money from me for the drug I gave my patient. I spend a large amount of time begging for the permission to order — to do X-rays; there are these audits about visit levels they call them, over pennies. One drug company thinks you should give chemotherapy without ever seeing the patient … you’re putting their life in danger.
It’s getting much harder because most doctors are employees, and in addition to the real problems they have to deal with a boss, whose priorities are far from anything about taking good care of patients.
The insurance companies pay me half what they pay a doctor in a big group for the same service. Because I’m not in a big group, they won’t negotiate with me. … So whether I can keep paying my staff, there comes an issue.
The lack of a single-payer system. We waste enormous amounts of time and energy dealing with insurance companies, whose major goal is figuring out how not to cover patients.
Fee-for-service medicine… drives overutilization and leads to poor outcomes.
I remember a patient who could not afford clopidogrel (Plavix), so he split his pills to stretch the prescription, but subsequently had a catastrophic in-stent thrombosis leading to cardiogenic shock and eventually heart transplantation.
Without a doubt, it is lack of access for many patients, especially the un- and underinsured…. I would have a tax-supported universal healthcare for at least minimum services.
The combination of exorbitant drug prices and multiple payers, which leads to coverage for medications based primarily on economics rather than published evidence and regulatory approved indications.
I have to come up with an alternate plan several times per week for a medication for which coverage was denied.
[I would change] the fee-for-service model and medical coverage linked to one’s employment.
The biggest barrier is that there are a large number of small barriers that add up. But if I had to choose one, it would be the crazy system of insurance and payments that we have in this country that is making things difficult for everyone.
[I would change] bureaucracy, red tape, and the perverse financial incentives that compel certain doctors to inappropriately treat patients to make a buck.
I had a patient who needed to be admitted, but he was worried that the copayment on his hospital bill would bankrupt him. I spoke with hospital administration, and there was little they could legally do… when he was in a vulnerable, painful place (physically and emotionally), his concern lay with whether receiving the care he needed would harm him financially.