I am writing because Im frustrated with the current and proposed state of healthcare in the United States. My concerns include malpractice liability and insurance coverage; the lack of tort or legal reform as evidenced in the current healthcare bill; the diminution of the primary care physician; and the potential loss of the primary care physicians guidance and control over a patients health regimen. I regard primary care physicians as “gatekeepers.” In such a scenario, the primary care physician has overall guidance and supervision of patient care. Another major concern is the disconnect regarding payment solutions for physicians. Such solutions appear headed for a downward trend over the next few years. My greatest concern is the projected future shortage of primary care physicians- a shortage that could be detrimental to our profession. The question of change in American healthcare is moot- change is manifest- but as part of that change I see no solutions for the problems Ive noticed.
Im compelled to write about my personal experience and describe a case that reflects my concerns. Recently, a consultant- a colleague to whom I referred a patient- admitted my patient. I find it ironic- as of this writing- that the doctor-patient relationship has changed, and I am now considered the consultant in this case and not the attending physician. The patient is one of the eldest I see, Ive seen him for several years and he is quite ill. Several consultants- nephrologists, hematologists, and gastroenterologists- are treating him, as well as me the family practitioner. The specialists saw the patient and documented that he was “dizzy” in the progress notes. Period. When I examined my patient I listened to his heart and heard an irregular rhythm. I ordered a stat EKG which showed positive couplets of PVCs. I ordered isoenzymes, a cardiology consult, a magnesium level, and transferred the patient to ICU. His blood pressure was less than 90/50. In a situation like this, there is no question in my mind that the primary care physician must follow his patient on a daily basis to ensure complete perspective of treatment- be the “gatekeeper” as I like to call it.
As a family practitioner, Im going out of business. Why? I dont get paid. NBCs Robert Bazell asked me, “Doctor, since the economy is so bad, are you ordering more tests? Trying to improve your income?” I replied, “No, Mr. Bazell, when any tests are done at my office, I pay for them upfront. I send the claim to the insurance company and in two-three weeks-maybe- I will get paid or perhaps incur other administrative responses such as additional requests for my records or other clarifications. It may take months before I get paid-if ever. Who paid for the x-rays, the EKG, the radiologist, employees, insurance, etc.? If we in primary care were surgeons and we paid for the sutures, anesthesia, bandages, etc., would we remain in our profession? We in primary care pay for all of that and if we ever get paid, it will be at the insurance price, for example, $1.95 for drawing a patients blood. As a result of this administrative “nightmare,” primary care doctors are referring out more, not following their patients in hospitals, retiring early, giving their practices away to hospital corporations for free, and so on. This is a dangerous erosion of our chosen field.”
I recently received a denial from Medicare for a patient seen in 2007. The patient came in for medical clearance before surgery, complained of chest pressure, and had an abnormal EKG. I couldnt ignore this and okay the patient for surgery- that would be irresponsible. I did a cardiac evaluation. To further explain the Medicare reason for delay or nonpayment, the stress test proved to be negative. Medicare focused on that result in its conclusion, which further explained Medicares reason for delay or nonpayment. Had I known the stress test would be negative, I would not have ordered it, however, I am a doctor not a magician. I must test to verify concerns and protect the patient.
Now, three years later, a woman presented to my office with chest pain and an abnormal EKG. She needed clearance for surgery. This time, I referred her to the Emergency Room. The ER doctor recommended that the patient be admitted. A cardiac consult was called and a evaluation was done, which included a stress test. The stress test was questionable, so a cardiac catheterization was done. The catheterization was negative and the patient was cleared for surgery, albeit with an additional financial liability close to $40-50,000. The patient I saw three years ago incurred expenses approximating $1,500. I didnt get paid for that procedure, and I no longer can pay for such tests upfront, so I referred the recent patient out for the evaluation. Who ultimately pays these bills? The U.S. taxpayer.
To summarize my points:
- Legal reform must take place.
- Primary care doctors should get paid for evaluating patients in their offices. This will cut healthcare costs by 50 percent.
- We need more primary care physicians. Residents are not choosing Family Practice. (Can you blame them?)
Whenever Im asked if I want healthcare for every citizen, my response is yes. Do I want coverage for pre-existing conditions? Affirmative. But everything comes down to payment solutions – and it is there in which my major concerns lay.
As always, not only as a doctor, but most important, as a patient, I am very concerned for medicine today.
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