Patient-Centered Medicine and the Struggle to Survive Obamacare

As we near some sort of attempt at compromise regarding the future of Obamacare, you will hear from health care workers that we need to bring the focus of medicine back on the patients.  The past few years, in which there has been a well-intentioned desire to control costs through bureaucratically oriented goals, the role of doctors and nurses has morphed away from patient care.  They have found that their role as “documenter of services rendered” through electronic medical records and coding for billing purposes has significantly taken away time spent with patients.

While it is important and necessary to provide accurate records of just what is wrong with patients being cared for at the doctor’s office and the hospital, there are problems with using the most highly trained, time-constrained, and expensive elements of the health care equation as transcribers and secretaries.  On top of that, the ultimate endpoint of the bureaucratic goals desired by the insurance industry and the government has an easily predictable result for doctors and hospitals.  That result might satisfy government overseers, but it is not an outcome health professionals, hospitals, and the communities that they serve desire.

Doctors and nurses have to comply with Continuing Medical Education (CME) standards in order to maintain staff privileges and licensure.  Throughout most of their careers, the primary topics of these hospital and community medical society presentations have revolved around the latest treatments in common and uncommon diseases, controversies, and the latest developments in health care.  Over the past few years, however, the most important and well-attended lectures regard medical coding, the means by which bills are justified and hospitals and doctors paid.  In the modern health care environment, proper coding is the difference between survival and bankruptcy.  But coding accurately is really very difficult, hence the need for enrolling doctors and nurses, and it is rarely ever done correctly.  And patients don’t often “fit” easily into a billing code that accurately reflects the work involved in their care.

While on its surface reasonable and defensible, the efforts expended on coding are in reality a bureaucratic attempt to normalize disease, outcomes, and costs.  With the use of coding, combined with the knowledge of the length of hospitalization and expenses involved, doctors and hospitals can be compared, and normative means testing can be used to get “outliers” back into line under the threat of financial penalty or restriction of business.

However, what everyone involved in the art of medicine knows, disease, and how it manifests in each individual, is rarely the same from one patient to another.  As an easy example, a middle ear infection in one child may clear up with no treatment, managed just by observation.  A middle ear infection in another child could progress to anything from a febrile seizure to sub-periosteal (under the skin behind the ear) abscess, and a prolonged hospitalization.  If coded in the slightest way inaccurately, the payment for that illness to the doctor and hospital could be obscenely inadequate to cover the costs involved with care.  How can this difference be quantified by a code?

Similarly, identical diseases may involve vastly different patients, without similar abilities to tolerate treatment and survive.  The same billing code for sinusitis in a healthy 15-year-old, an illness that can clear 85% of the time without treatment, is used when describing efforts to treat a resistant bacteria in an immune-compromised 15-year-old transplant patient.  Any attempt to align costs and care differences between these two patients is probably beyond the scope of any bureaucratic entity.

So, in an effort to survive financially as reimbursement decreases, focus is necessarily placed much more on checking “meaningful use” boxes on standardized computer models distributed to doctors and hospitals to help them comply with the recent guidelines put out there by the government and insurance companies.  Interestingly, the “selling point” of these computer models is that they can “capture more dollars” if only a few “rules of the game” are followed.  Costs per patient are going up as a result.  This was predictable.  While expense increases, time actually spent with the doctors and nurses is decreasing.

The other disconcerting, and also easily predictable, result of this bureaucratic mess is that it will sort out hospitals based on relative cost.  As anyone with any elementary skills at logic could foresee, this will result in hospitals turning away those who are very sick, trying to “dump” them on other hospitals.  Consequently, hospitals will expend significant effort trying to attract doctors who treat relatively well patients with illnesses that are easily treatable.  Those doctors who have very sick patients will settle into those default “dumping ground” hospitals.

Eventually, the financially viable hospitals will be in the areas in which healthier people live, and the dumping-ground hospitals will have to be subsidized by the government in order to survive.  Not only that, but doctors who choose to treat the sickest patients who are most at risk for complication will actually be penalized, because their costs are outside of the norm.

Obamacare, the “free” health care envisioned by the most naïve among us, is a massive bureaucracy, sold to us as a cost-cutting, fairer alternative.  The bill described 247 new departments to manage the process.  Hospitals and insurance companies have created departments to pry monies away from this colossus.  (These are dollars that could have been used to treat the sick.)  The only way that costs are in any way slowing is the added factor of high-deductible insurance scaring patients away from treatment in the first place.  And the ultimate result of this well-intentioned but predictably bad policy is that the rich will have the good hospitals, and the poor will not.  The rich and relatively healthy patients will have the happy doctors, and the poor and sick will not.

Health care professionals want to have time with their patients.  They dread the time spent checking boxes on a computer screen in order for a distant bureaucracy to tell them that their billing is outside the mean.  They rue the process that will inexorably swing toward certain hospitals surviving only because they turn away the very sick.  They want colleagues they can rely on to transfer their biggest problem patients, without having to worry that they will be the first to suffer financially and the first to ultimately “bail” on the system.  They can sense that, left the way it is, Obamacare is meant to “crash the system,” leaving them at the mercy of the federal government and with the vast majority of patients on Medicaid.

Becoming more patient-centered will be relatively easy.  Strip away a good bit of the size of the entity managing the dollars.  That way, more will be left for individual patient care.  Look into the silly restrictions on portability of policies, not competing across state lines, and allowing insurance pools.  Just don’t expand what is already “the Borg,” as it will surely lead to higher costs and less care from those with the most to offer.

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