"20 Years In"

James Bowers MD FACP

OK, well I am over 20-years in at this point and I feel that I need to share my observations as an internal medicine doctor.  I was sprung from internal medicine residency in the early 90’s when medicine was entering its managed care phase, a la “Hillary-care”.  Interesting that the health insurance industry adopted the Clinton style healthcare plan without actually being mandated by congress to do this sweeping healthcare reform.  It was doomed from the start.  Overnight, managed care networks sprung up and most doctors became part of “The Network”.  After about 5-6 years it was determined that the managed care networks cost more than traditional fee for service (this is the Marcus Welby plan where you saw your doctor, your doctor billed your insurance and then was paid for the service). By 2001 all of these plans were scrapped and fee for service was resumed.  This was the plan that was driving up health care costs across the country.  

Emergency rooms were flooded with patients who preferred to get their primary care at the emergency room.  Odd as it seems, I thought that emergency rooms were for...like, emergencies.   It doesn’t make sense that someone would visit an emergency room for an earache or sore throat.  To visit an emergency room meant blood, guts and other unmentionable bodily fluids spewing forth.  Additionally, hospitals had no limitations on who could be admitted, therefore, business was booming.  Hospitals raked in the dough by admitting everybody.  Quick profit lead to quick regulation and soon hospitals had to go through a gauntlet of regulations in order to get Grandma with a pneumonia admitted.  Those sly hospitals at first found a loophole in this plan and actually didn’t admit patients to the hospital and deemed these sick patients as “observation” patients.  Either hospitals forgot or neglected to tell Grandma that she wasn’t actually admitted to the hospital for the 3 days that she was there in a bed receiving IV antibiotics, 24 hour nursing care and daily doctor visits; it was a complete delirious dream!  This was the time that anyone who had the letter “C” in their title in the hospital or health insurance company (CMO, CFO, CBO, CEO, C-choose any letter from the alphabet-O) was making more than the doctors who were actually doing the work!  I still scratch my head how a hospital board can justify the salary, benefits and profit sharing of a CEO that exceeds $750K per year (that’s on the conservative side).  Meanwhile, all of the “C” people in the insurance companies were making even more. I remember reading a report of a “C” person at United Health Insurance making A BILLION in salary, benefits and stock.  (You may insert your “WTF!!” Here.)

OK, let’s go forward to the current situation. We are 4-5 years into the “affordable” care act (ObamaCare) and we are no better off than we were than in the past.  Yes, a mandate to insure every American is a good idea, but this means that we all pay more for less care.  By less care I mean physical exams that last exactly 15 minutes and do not even come close to the needed information that any doctor needs to have in order to have a full picture of someone’s medical profile so they can treat them appropriately.

Overnight, it seems that my medical colleagues have been transformed into something out of “Invasion of the Body Snatchers”, they’ve become employees working 9-5, seeing patients for exactly 8 minutes, wearing tracking devices (yes, I am not exaggerating) to trace and track their every move in order to make them as efficient as Toyota Camry builders.  The focus is on quantity and not good quality.  By the way, good quality healthcare involves a good understanding of each patient that a doctor is serving.  This takes time to develop and can’t happen in today’s American mega-clinics.

Health care insurance companies are not off the hook for their part in creating this inefficient, de-personalized and inferior healthcare system.  Health care insurance companies are poorly run to make processing claims run smooth.  Medicare (YES, Medicare) runs a more efficient health care insurance company than ALL of the health care insurance companies in the nation.  Their overhead is lower than all the rest and they pay on time.  My office has a dedicated person to fight with the private insurance companies with appeals, non-payments and other made up reasons to not pay doctors for their service.  This is nuts.  Do you think that we shouldn’t delve into the so-called single-payer system that all of the other first-world countries have been doing for years?  We can’t afford not to.  Besides, Grandma and Grandpa get better healthcare than you do and they are paying less.

Doctors have been replaced by “care providers”, nurse practitioners and physician assistants who are practicing beyond their training.  Strange, but true, executives of major hospital chains (it doesn’t matter if they are “for profit” or “not for profit” they all act to please their boards) went to Japan to learn how to make their “care providers” (no longer physicians, doctors) more efficient, like robots.  Now, there are primary care providers, but these are physician assistants and nurse practitioners who are not functioning under a board-certified physician.  Walk into your local “Urgent Care Clinic” and you will be seen by a nurse practitioner.  He or she is fine if all you have is a sore throat or cough, but more complicated medical issues like heart failure and diabetic complications should be handled only by medical doctors.  These complex problems are outside of the reach and understanding of nurse practitioners unless they are operating in a cohesive team with a medical doctor.

I can’t think of a worse time for healthcare in the United States.  We deserve better than this.  Honestly, the only way out of this mess is to offer Medicare for all citizens.  Other options are inferior to this plan.  We have to do this now.