The Herd of Elephants in the Room

I think people are generally unaware of the herd of elephants present in the room during a visit with your doctor.  These elephants have to disappear, at least into the background, if we are ever to find a solution to affordable, quality healthcare.  90 percent of the doctors time and mental energy and focus is to the elephants, not you.  He doesn’t have a choice.  At least, not a real choice.  The alternatives are bankruptcy or jail.  Our healthcare system is such a complicated maze of regulations from the government, insurance companies, and even medical organizations, that cost efficient, simple direct solutions to day-to-day problems are stifled.

Elephant #1 – The Government

I will illustrate this elephant using one aspect of the Affordable Healthcare Act.  The government, in its infinite wisdom, decided that all doctors should be using electronic medical records and that these records should be interfaced in such a way that one computer could talk to the other computers and healthcare information would be readily accessible.  They created a rewards/incentive program paying doctors tens of thousands of dollars of your tax money to get doctors to do this.  The program is so complicated it spawned an entire industry of advisers (comparable to tax attorneys) to help doctors satisfy the requirements of the program so they could get their incentive money.  Some of the advisers were either government employees, or subsidized by the government to do this work.  Never mind that the vast majority of existing EMR (electronic medical record) software sucks.  It generally decreases the efficiency of the delivery of medical care, when it works, which is certainly not 100% of the time.  It certainly increases the cost to deliver medical care.  And the interfaces ….   Give me a break!   They don’t work the way they are supposed to.  But, the government says, if you want to get your incentive, you will do this.  The end result is the doctors of the USA are spending their time attempting to comply with and satisfy the requirements of a program, that will not, at least in its present state and form, achieve the targeted result.   The consumer is paying for this in their taxes and then paying for this again in the resultant increase in cost of the delivery of healthcare.  Not only that, the quality of the healthcare received is diminished by the distraction imposed by the program.  Think about it.  How long does your time with a doctor last during an appointment?   5, 10, 15 minutes ?   If a few of those minutes are required to comply with this program, it is a huge percentage of the entire visit.  Now multiply that times the number of doctor visits in the USA annually.

Elephant #2 – Medical Insurance Companies

Nowadays, as a physician, try to do anything; order a test, make a diagnosis, write a prescription, etc. and you know what the first question you have to ask is?  “Which insurance company do you have?” .  And you know why you have to ask that question?  It’s because they are paying for everything on behalf of the patient and they tell you what to do.  If you don’t do what they say, they will not cover the service.  The patient is unlikely to find it acceptable to pay out of pocket for something their insurance company “covers”.

Now imagine 1000 different medical insurance companies with 100 different sub-plans each. That yields 100,000 plans.  Now consider that each of these plans is in a constant state of revision and updating so that the rules for each of these plans are changing every day.  How can anyone be expected to keep track of it, even if you wanted to.  And guess who’s fault it is if one of the things you order is not covered by the insurance.  Yes, you guessed right.  If you think I’m exaggerating, ask your doctor.

Many of the “covered” services require “pre-authorization”.  I once read an article in the New England Journal of Medicine entitled “Inconvenience, The Secrete Weapon of the Insurance Companies”.  Practicing medicine today, doing your core job and the ton of BS added on to it by this nonsense, how much extra time do you think you have to jump these extra hurdles.  You guessed right again.  So you avoid jumping them if possible, just to get through the day.

Elephant #3 – Malpractice Suits and Insurance

If you live in the USA, you know that suing is a #1 national sport.  It is our way of life.  If you spill coffee on yourself at McDonalds, you sue McDonalds, etc.  Medicine doesn’t have a monopoly on this issue.  However, medicine is an inexact science.  Contrary to what TV shows would have you believe, doctors don’t have 100% knowledge, treatment efficacy, and luck.  Sh&*t happens!  And when it does, the doctor is the prime target for the “blame” regardless of whether or not any error was made.  Doctors pay enormous amounts of money each year to protect themselves against lawsuits.  This has the unfortunate side effect of encouraging lawsuits since the potential gains of a successful suit are exponentially magnified.  Even if a suit is frivolous, it will result in enormous legal costs.  Eventually the patients pay for this via increased medical costs, but people who sue are not concerned with that.  Often, a completely innocent doctor will settle based on legal advice for expediency.  These cases often go on for years.

In this environment, the physician is viewing the world through “malpractice lenses”.  Every, and I emphasize EVERY decision that he makes is viewed from consideration of malpractice.  This results in more tests and treatments being ordered than necessary to “cover your ass”.   Again, the cost of this is passed on to patients in higher medical costs.

Elephant #4 – Electronic Medical Records (EMR or EHR)

At one time I wrote software and marketed it nationally.  I wrote a medical practice program to run my office which we used for 10 years.  I eventually replaced it because nobody could support it besides myself and I had to take my laptop on vacations, etc. to support the program if there were problems in my absence.  I am acutely aware of how wonderful and helpful computerization of the running of a medical practice could be, provided the software is designed well to assist, rather than get in the way of doing your job.  It could be heaven.

With the software currently available, it is, instead, hell.  It takes far longer to document what you are doing on the computer, than the time it used to take doing it on paper.  As a result, your productivity diminishes.  It costs more money, so that, along with your decreased productivity, decreases your profitability.   To be used properly, so that the data can be coded in a way that it can be searched and reported on, words have to be changed to codes.  The relationship of the words to the codes is sometimes one to many, instead of one to one.  That is, one code could represent multiple possible phrases.  This can result in the computer rephrasing what you are trying to say, changing the meaning of it.  To attempt to compensate to make things faster, templates are created to rapidly input common groups of things you would say or do in a certain situation.  This results in things being inadvertently  entered into a note that don’t match the reality of the visit.  The software frequently outputs a note that speaks in a way that no human would speak or express himself, and is difficult, if not impossible, to understand.  In order to get paid, you are forced to note a huge amount of “negative findings”.  So much so, that finding what happened during a visit is like finding a needle in a haystack.  (This represents all 4 elephants working together)

So, if you were thinking your doctor visit was “too short”, the time he had left for you, after dealing with all this nonsense, was far shorter than you realized.