Sunday, September 26, 2010

Why (Single) Family Practice is Dying

There have been many articles written by family doctors in medical magazines about the present difficulties in the profession, the "good old days", and reasons for retiring early, but few, if any written for the patients, so they can understand the problem. The following is an attempt to remedy that lack. (And please feel free to forward this blog to your local Congressman, Senator, and legislators in your state's capital.) I was stimulated to write this blog by a friend of mine who has recently retired from the solo practice of internal medicine, because (a) he was spending more time on the phone with insurers and with paperwork than he does on patient care, and (b) because his net income was dropping each year so that his retirement annuity now exceeds his net income, even though he still enjoys the practice of internal/family medicine.

The main problem revolves about the amount of time that he needs to spend in non-patient care, and time is his least fungible resource. For instance, he now has to certify the need for home visits by a nurse weekly rather than monthly, and name stamps or his secretary's signature is not accepted.
This is an additional 23 pieces of paper he had to sign every Monday.

If a deaf MCR patient requires a sign language interpreter, the doctor must pay for it out of his own pocket, which costs more than what MCR pays him for the visit.

The HMO's such as Oxford keep on writing him letters to fulfill their HEDIS requirements to the government asking him why his diabetic patients have not received their yearly eye exam or his female patients their yearly mammogram. He then has to take time to explain to Oxford that the patient saw a non-Oxford ophthalmologist or radiologist, and since he was not the referring doctor he does not have a copy of the report.

He continually has to get permission for a MRI rather than a CT scan (HMO, not MCR), or explain to MCR part D that the generic medicine does not work, and the patient needs the brand name, or explain to the HMO that OTC Claritin does not work in this patient, so he/she needs Rx. Allegra or Xyzal.

He gets paid much more for doing than for thinking: MCR pays more for a 10 minute pulmonary function test than for a 30 minute visit. This is because MCR and HMO's can't measure thinking and diagnosing, but they can ask for a copy of the test.

The hospital now has an electronic order system. It used to take him 5 minutes with pen and paper to admit the patient, and now it takes 25 minutes to go through all the templates, including the birth date of the doctor (and how does that help patient care?) and whether or not his private patient should get a flu shot at discharge. Again, all this takes time, time, and time.

But if he wants to give a Botox or Restalen injection, which HMO's and MCR don't pay for, he needs supply them no proof, get no permission, and charge whatever the local traffic will bear.

A few years ago, MCR asked him why he did more flexible sigmoidoscopies than any other internist in his county. He wrote back to MCR asking them why more internists didn't look for colon cancer in their patients. He never heard from them again. Clearly MCR was more interested in reducing the number of (more expensive) financial outliers than in ensuring the good health of MCR patients.

If I write you a prescription for a sleeping pill, I make it PRN, i.e. take it if you can't fall asleep. That has been an illegal order for any MCR patient in a nursing home since 1996. MCR decided that the nursing home nurses on the night shift would be tempted to drug their patients so the nurses could have a quiet night. So I either have to write for a sleeping pill every night, which is bad medicine, or come in to the nursing home on the same day I want a patient to have a sleeping pill. The answer: I stopped seeing all nursing home patients, and let the assigned nursing home doctor worry about the problem. Once again, I didn't have the extra time.

And if I saw two nursing home patients in a nursing home the same day, I got paid less for the second one, because MCR claimed I was there already, so maybe I didn't really have to see the second patient. This was another reason to stop seeing nursing home patients, because again it took up extra time that I didn't have.

Federal MCR rules require that the rear doors of nursing homes be locked during the night, so demented patients can't wander off, but state laws forbid the locking or rear fire escape doors at any time while the building is occupied.

HMO's have their preferred list of brand name drugs, and it takes a lot of arguing with them to convince them that Prevacid works and Prilosec does not in my particular patient, or that I want my diabetic hypertensive patient to have Coreg as a beta-blocker because it is the only beta-blocker that has been shown to reduce microalbuminuria in these patients.

If I had my way, no insurance company, HMO, or MCR outfit would be allowed to challenge any Rx, Xray or blood test ordered by a doctor, and we would really save a lot of time.

The government is pushing computerized EMR's and drug ordering systems, which is another recipe for wasting time. There are a lot of (sometimes theoretical) drug conflicts listed in the PDR, and the computerized order system mindlessly follows them. The fact that the warning has been superceded by more recent research never makes it into the PDR, because it would cost the drug companies too much money. For instance, it is NOT true that beta-blockers cause depression (see, for instance, NEJM article from 3 years ago), but every time I try to add a beta-blocker to a patient on an antidepressant, my hospital's computer flashes an alert, and I have to manually put in an override command. I even got flashed for putting a young patient on a calcium channel blocker, with the warning that there were more efficient anti-hypertensives. In fact, I was using the Ca++ blocker for the well-recognized off-label use of reducing esophageal spasm, and again this explanation/override took time. And don't even think of using a tricyclic anti-depressant for stomach acid suppression----no computer has ever heard of such a use!

Unlike lawyers, doctors cannot charge for telephone advice, but we can be sued for it.

And we don't need tort reform so much as we need removal of the contingency fee from medical malpractice cases. Let it all be no-fault, similar to some states' mandatory automobile insurance policies, and let the workman's compensation fee schedule prevail for doctors and lawyers. And no, the threat of being sued for malpractice doesn't make a doctor a more careful physician. No doctor wants to harm a patient, either by omission or commission. But the threat of malpractice suits makes us order many more Xrays and specialty consults than we think the patient really needs, and in some counties (e.g. in Florida) no neurosurgeon covers the emergency room, because all automobile accident injuries end up in court. Similarly, no OB attending trains his residents in the use of forceps, because of the risk of a malpractice suit when the doctor is asked:"if there was a problem, why didn't you do a C-section?" That is why the number of C-sections has increased.

I still think that medicine is the most wonderful and rewarding profession in the world, and I also feel that internists have the most enjoyable specialty because we get to be real family physicians and take care of three generations of the same family. But all my children are educated and married, my mortgage is paid off, and I don't need that much income. I don't know if I would choose this specialty if I were starting off today.

I wish all doctors had time enough to spend more time with each patient, but I have no idea how to achieve this.


  1. "I wish all doctors had time enough to spend more time with each patient, but I have no idea how to achieve this."

    The answer is so obvious, I am surprised it eludes you.
    The answer is to eliminate third party interference in medicine.

    If patients paid doctors directly for what mattered to them, rather than relying on a third party to pay for what matters to them (saving $) then doctors could go back to doing what they love - caring for patients in the best way *they* know how.

    This can be accomplished with HSAs for primary care, and high-deductible plans for expensive care.

    Indeed, this is the ~only~ thing that will save primary care. If only anyone would listen

  2. This is a variation on boutique medicine, and I agree with you. Many doctors on the East Side of New York City, all of Boca Raton, and other places have such a system.But right now not enough patients would join such a plan across the country.

  3. Exactly, but it doesn't even have to be "boutique" medicine to be successful; just eliminating the overhead required to deal w/ third parties saves tons of $$$$

  4. Apropos of the above, more and more doctors are getting fed up with the last minute reversal of the annual 20% reduction in MCR fees required to make MCR revenue neutral, and more and more doctors are dropping out of Medicare entirely. In states where the state (e.g. N.Y.) mandates that all insured patients, MCR and non-MCR receive the same hospital doctor bill, these same doctors are letting the hospitalists take care of the patient, similar to the British consultant system.
    I know some groups where each doctor accepts only one of the HMO's, and at the end of the year they drop the least profitable HMO and sign on with another.