The NY Times has an article about the impending doctor shortage that should finally end the myths about doctors but won’t. In 1993, the Clinton health plan was rejected by a public that was pretty satisfied with its health care, no matter what the single payer enthusiasts say. I was still in practice and, while the burden of bureaucracy was growing, medical practice was still pretty satisfying.
The year before, I had finally bought an office computer system. I have been a computer user since the PC first appeared. I was a programmer and engineer before I went to medical school but, in those days, unless you had a job in a big company, computers were something you saw in the movies, like “2001, A Space Odyssey.” A surgical practice did not need the primitive computer billing programs of the 1980s as they were directed to a high volume of small charges. Surgeons tend to see fewer office patients and many of those office visits do not generate charges (or didn’t then), at least for general surgeons. The office patients were either new patients, who might not be charged separately for the visit if they were scheduled for surgery, or post-op patients whose visit was included in the global fee for the surgery. I also had a policy, adopted from the surgeon with whom I had been first in practice, of not charging post-op cancer patients. In fact, I rarely charged post-op patients at all on the theory that, if they had a problem, I wanted to see them again and wanted to put as few obstacles to another visit as possible. This avoided potential dissatisfied patients and it established a relationship that patients usually do not have with the surgeon. They knew who I was and might come back with a new problem. General surgeons rely on referrals and it was helpful to have the satisfied patient know my name if something came up in the future.
I finally bought a computer billing system (It cost $36,000 plus the computers) because they had gotten more sophisticated and, by 1991, I had 276 contracts with various insurance companies and HMO organizations. That was the era of the “HMO without walls.” Insurance companies and for-profit HMOs had learned that they could sign contracts with individual doctors, or with groups of doctors, and use these contracts to control costs. The contracts were complicated and many had different provisions that had to to be tracked or there could be a refusal to pay or even a penalty. In one instance, I found that sending a patient to the closer medical lab for a wound culture resulted in a $500 dollar fine for me from the HMO. The lab fee was $36. The result of that incident was that I refused to see HMO patients in my second office in San Clemente, even if the patient lived in San Clemente. I could not rely on my office staff to always get the patient to the correct lab or x-ray office.
The second consequence of this incident, and others like it, was that I bought the computer and linked it to the other office. This way, my staff could enter the patient’s insurance information and get a list of all the rules for that particular HMO or PPO. Since I left practice in 1994, it has only gotten worse. For primary care physicians, it has gotten a lot worse. Fees have been cut and bureaucracy has increased. I am now part of that bureaucracy for the Workers Compensation system, as I do reviews of cases that are not being treated within guidelines established for this system. The reason why there are such complex guidelines is the amount of fraud and waste in the system, now much reduced since the reforms began five years ago in California.
What has been the result for the nation as a whole ? Primary care physicians have been less well paid and have been deluged with bureaucracy. As a result, they have been leaving the field. I tell medical students that, if they plan to enter primary care, they should get an MBA as they will be managing nurse practitioners and physician assistants. More and more of the primary care is being delivered by these “physician extenders.” Some physicians are natural managers. Many don’t go to medical school to do this and they simply avoid the field or retire early if possible.
We’ll see if Obama and the people around him recognize this. They strike me as a bunch of theorists and academics who will not understand this problem.