Wednesday, February 17, 2010

What's Wrong With Our Healthcare System. One Doctors Perspective

I recently read an article about soaring health care cost. Part of the new health plan initiative is to crack down on fraud and abuse by providers. Auditors and government agencies have testified at recent congressional hearings that they will hunt down the offenders and solve medicare's financial woes. They did agree reluctantly that some of these cases are due to clerical errors rather than actual fraud. Here is an example of such a case.

In order for a patient to receive medical supplies, a physician must fill out lengthy forms (that the physician cannot bill for) . A patient needed a walker after a sustaining a fractured pelvis. The medical necessity form was returned to me several times because a change that I made on a line item was initialed but not dated. The form was returned back to me because the date that I added not re-initialed and then again because it was not re-dated. There were four sets of dates and initials because I originally wrote the wrong age for this patient. Because of my original clerical error this case was deemed to be a fraudulent claim until I corrected my clerical error. Doctors in practice see these absurdities all the time.

In my opinion, our health care system is ailing because of misguided values. It is a system that rewards reactive rather than proactive behavior. It values procedures rather than outcomes. Insurance companies don't blink an eye when they have to pay thousands to remove a lung from a cancer patient. But they will not pay for smoking cessation. Physician's cognitive skills at history-taking, physical exam prevention are undervalued. Conversely a test such as an MRI is reimbursed many times the cost of an office visit. What is the value of counseling a patient about home safety and fall prevention versus the cost hip surgery and possible permanent nursing home placement. Ridiculous policies lack any remote connection to common sense. This is not more evident than in the frequently encountered situation of the patient who needs long term IV antibiotics. Medicare will pay $10,000 or more for temporary nursing home care rather than pay for home services at a fraction of the cost.

Medicare and insurance companies are not the only culprits. Consumers want the "latest and the greatest". They object when doctors don't order a branded drug when the generic drug will work just as well. And our lawyers will always always steer us toward ordering more test and consults. Our health care environment promotes chartsmanship over a substantive encounter. Fill in the correct boxes in the medical record and spend more time with the chart than you do with the patient and you will be ok. That why EMR's are so good at spitting out pages of verbal garbage that will satisfy the auditors and lawyers alike. And self-serving government watchdogs will hide behind bureaucracy and will never work themselves out of a job.

Now that I have enumerated the failings of our health care system I have all the solutions. But that's a topic for future discussions. However, I will give you a sneak preview.
(Encourage primary care at the med school level, year of social service, higher reimbursement for cognitive skills, bonus based on outcomes, eliminate bureaucracy (less government), tort reform, incentivize the consumer to take some responsibility for health care cost, encourage prevention etc)

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