Tuesday, June 24, 2008

Dissatisfaction in Medicine

I ran across this story from the New York Times earlier this week. It's not really news; doctors have been dissatisfied with the state of medical practice for years now, for a variety of reasons. But . . .

I asked when his work usually got done.
“It is never done,” he replied, shaking his head. “See this pile?”
He pointed to five large manila packages on a shelf above his desk. “These are reports I still have to finish.”

Wait a second. Is this guy dissatisfied with medicine, or is he just overworked--by his own choice? These are reports I am assuming the doctor has generated himself. The way reimbursement works is you have to document in some fashion (like a "report") what you have done, say, to diagnose or treat a patient. These reports weren't assigned to him. He has to complete them in order to get paid; actually, the hospital and clinic he works out of won't get paid either until they get done. Is he griping because he has too many? Why is this guy then working so hard? Does he have too?

I liked this quote, too:

“I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.”

Now this guy is an internist, but I will still bet that the 'scrips he was called on were those he had written for new drugs that had just been released and that cost a lot of money to fill--money that comes from somewhere, either the patient's pocketbook, or the insurance company's funds. I'll bet he had no idea how much the prescription cost. Most of us in practice are woefully naive as to the specifics of how much our patient's drugs cost. But he's upset because the insurance provider wanted him to find a less expensive, equally effective drug. Is that a bad thing?

Then there's the MRI issue. An MRI is a great technique for imaging structures inside the body, but it is not always the best way to look at different areas. It probably doesn't need to be ordered on a patient who is already hospitalized, as it is more often indicated as an outpatient diagnostic tool (for inpatients, a CT scan is more likely to help a doctor make a timely diagnosis, and is far cheaper). As a gynecologist, I am often referred patients from other physicians in other specialties who have diagnosed a patient using MRI. An ultrasound is much more useful in imaging pelvic structures, and again costs hundreds of dollars less. I don't know--maybe this guy doesn't know much about how insurance utilization and reimbursement works.

There was a "Golden Age" of medical practice, somewhere back in the 60's and 70's, when you as a physician could hospitalize patients whenever you wanted to, for whatever reason ("nervous exhaustion," etc.). You did a cataract extraction, or a hysterectomy, and sent the charges in to the insurance company, and were promptly paid for the work you had done. But as medical costs began to soar, the insurance providers began to wake up and hold physicians accountable for the costs attributable to them. Utilization review became the fashion, and suddenly, almost every facet of medical practice became subject to scrutiny and approval--hospitalizations, surgeries, prescriptions--all things thought to solely be the doctor's sole private prerogative. Although the review process is less extensive these days, it is still around.

I never practiced in anything but a managed care setting, so maybe that's the only thing I am used to; it doesn't bother me as much as it does some of my colleagues. In some ways it's bad; it truly is hard to try and explain to some coding clerk why your patient is not stable enough to go home. In some ways, however, it provides some needed oversight for medical practice. I suspect that the "Golden Age" was perhaps not so "golden" after all.

There are a lot of areas of medical practice that need reforming and retooling. If you decide, however, that you want to work your butt off, then get busy. You can only kvetch at yourself.

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