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The Elephant in the Exam Room: How Insurance Companies Affect the Doctor-Patient Relationship

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I had a moment of sadness come over me last night during a dinner with a long-time medical doctor who is both my friend and colleague. I have known him for more than 30 years. To me, this man represents the standard for excellence in family medicine. He is celebrated by his patients, a number of whom are the third generation of family members to call him their doctor. To become a better advocate for his patients, he has never stopped learning. He has attended more post-graduate medical courses than any family physician I know. He has been certified in many specialties, including sports medicine, cardiovascular stress testing, chronic disease management, nutrition, and behavioral medicine. He has taken leadership and communication courses to be better able to relate to his patients. He has provided his private cell phone number to his patients with the understanding that they will not abuse the privilege of 24/7/365 access, and they have not. He never thinks he can know enough, and drives himself and his staff to do more to provide continually improving preventive care for his patients.

So why my sadness? Because I learned that, like many other patient-centered physicians, after all his years of excellence in practice, he is undergoing continued harassment from major third-party payers because his practice doesn't fit into the standard of care: the six-minute office visit and routine diagnostics. Rather than rewarding him for the job he has done in keeping his patients out of the hospital by implementing aggressive personalized lifestyle medicine, he is penalized for not following a road map known as "usual and customary" care.

The medicine that third-party payers would like him to practice is formulaic and prescriptive. It is built upon a mass production "efficiency" model of high throughput. It is not built upon the emerging science that supports the cost effective delivery of personalized preventive care. The medicine the insurance companies would like him to practice uses the prescription pad as a device to compress the time a doctor has to spend with a patient. It is a medicine where a diagnosis can be created in a matter of minutes and a prescription is the socially acceptable termination of the discussion with the patient about their problem. It is a medicine that looks primarily for the presence or absence of a disease, and not a medicine that takes the time to create a personalized path to good health. It is generic medicine for the average person. But an average person doesn't really exist because as we have learned in the post-genomic era, everyone is different. It is "medicine-lite" that has been dumbed down to the extent that many of its practitioners don't want to ask the "emperor has no clothes" question: Is this how I expected to practice medicine when I decided to become a doctor?

In my experience over the past 40 years as a medical researcher and educator who has had many hundreds of bright and capable students, I have been impressed by the level of dedication and interest in helping people that characterizes most young practitioners. But something happens to many of them along their journey of life as physicians; their ability to think and act as an advocate for their patients -- a role that drew many of them into medical school -- is lost over time. It is lost because the system makes it difficult to maintain their incentive to put the patient first. Over time, the medical "standard of care" replaces their ability to think and act in the patient's best interest. Their practice becomes routine and their patients all start looking like a diagnosis.

So back to my sadness. If medicine cannot accommodate the type of thoughtful, caring and committed doctor represented by my colleague, how is it going to deal with the rising prevalence of complex chronic disease that we are witnessing? The formulaic medicine we are providing as a standard of care for chronic disease is not working, and the situation will only get worse as more aging baby boomers move into the chronic disease arena over the next 15 years.

It was my naïve hope that our understanding of the need for a new clinical approach to the personalized management of chronic disease had evolved to a higher level. In the 1980s when I was the director of a medical laboratory providing services to a preventive medicine clinic in the Seattle, Washington area, there was a Medicare review of one of our doctors' patient charts. The determination was that he was very effective in keeping his patients out of the hospital due to the focus on prevention, but that his charges for laboratory and other preventive services were "out of range for a general practitioner" and he was reprimanded. The argument that the increased cost of services on the front end saved significantly more expense on the back end of hospital services was said to be irrelevant because there were two different review bodies for evaluation of these expenses and the two groups didn't talk to one another. It was my hope that 30 years later this would have changed, but unfortunately it hasn't.

So what do we do? It is critically important that we find new ways to manage chronic disease early enough to prevent the use of costly medical services that are necessary during acute care. We must pioneer a clinical approach that focuses on personalized lifestyle medicine and engagement of the patient in their own program. We must support the creation of healing environments in the office like those found in the office of my associate. We must find ways to incentivize personalized preventive care. The new system needs to find ways to provide esteem for physicians that go the extra mile to become proactive and pursue continual learning in the areas of exercise science, nutrition and behavioral medicine. We must find a path to celebrate innovation in managing chronic disease and creative thinking about improvement in patient engagement.

We must develop a system that provides for a reimbursement model that allows a physician to make a decent living providing personalized preventive care to their patients.

We are at a very critical point in the evolution of the medical model. The decisions that are being made to drive medicine into conformity and standards of care that discourage the adoption of a personalized form of preventive medicine will result in an increased burden of hospital-based medical services. We must find a way to celebrate our heroes in medicine who are creating excellence in delivering personalized preventive medicine every day in their practices. We need to learn from them what the new model of health care needs to incorporate to improve patient outcomes.

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