As the health reform debate rages on, the central issue of how to improve care while reducing costs remains unaddressed.
Fee-for-service has reduced doctors to assembly line pieceworkers, paid by the office visit and procedure rather than by effectiveness of treatment. The result is an inefficient, costly and dangerous system. It is not unusual for a five minute office visit, which excludes clinical examination or note taking. Many patients/consumers can be seen in an hour. Time is money. And let us not forget those insidious, endless co-pays. The perfect storm is gathering as health care costs are now 17.3% of the GDP and rising.
Doctors and patients once had a close, almost familial, relationship lasting decades; a relationship seen in the success of the Veterans Administration, whose doctors are salaried. Today, seeing a doctor is short and impersonal as we shuttle from one "provider" to the next. How can this approach serve a patient better than a doctor engaging in dialogue and a thorough clinical examination?
I recently experienced how fee-for-service "health care" works up close, and I would like to share my own experiences here.
Two years ago I fell down stairs and was whisked off to a major New York hospital. I was seen by an ER doctor, not an orthopedist, which the injury clearly warranted. X-rays were taken, I was given a soft leg brace and a cane and discharged. The $35 cab ride home was the first of many costs to follow.
The following week I saw an orthopedist recommended by the hospital -- one of only two names offered, the other being their Chief of Orthopedics. A father and son duo. The young doctor briefly touched my leg, announced that I had torn a calf muscle and would be fine in six weeks. His specialty knee replacement, and since I didn't need a knee replacement, I was dismissed in under ten minutes with no follow up visit recommended.
Needless to say, I was not fine in six weeks. I saw another orthopedist who took X-rays, administered a cortisone shot and prescribed physical therapy at an office he owned, without an examination of the injured leg. At my next visit, I insisted on an MRI, and the doctor was surprised to find I had a torn ACL and meniscus; he thought I had simply a small knee tear.
During my visits, this doctor would simultaneously see five patients and was constantly interrupted. Back and forth he went, and I marveled how he could even remember each person's issues.
It was now time for orthopedist number three. This doctor prescribed additional physical therapy and recommended I see a physiatrist at her hospital's spine institute, thinking my leg problems were caused by my back. She couldn't understand my continued difficulty walking after so many months.
The physiatrist was seen, two MRIs of the back and cervical spine taken and a cortisone shot arranged, without any warning of its dangers (osteoporosis and stress fractures) or its 50% failure rate. The physiatrist diagnosed two herniated discs, which I did not have, then suggested another cortisone shot higher up in my back. The MRIs showed stenosis of the spine suspected as the root of my problem walking.
The hospital was paid $3,200 for the cortisone shot. A puncture of the skin, an injection is considered surgery and paid accordingly. I refused to pay a $100 deductible, instead expressing my displeasure at my treatment in a letter to the president of the hospital. So far, no response.
Since then, I have seen a spinal neurosurgeon who recommended two back surgeries, though I had no back pain. The first surgery has a 20% failure rate; the second surgery would fuse discs and add a rod to my back. No explanation was given as to why a second surgery was a possibility.
I have also seen three neurologists and was administered a $1,500 EMG test with no negative results, and have also been misdiagnosed with herniated discs, carpal tunnel and a pinched nerve in the neck; all nonexistent. Then there were 30 physical therapy sessions on my injured leg and 7 traction sessions on my back, at which my neurosurgeon laughed. I am reminded of snake oil salesman of another era.
This endless journey has delivered poor results at great physical, emotional and financial costs. I am convinced that fee-for-service and doctors' defensive medical practices must be addressed in reform, along with medical malpractice. We can learn a great deal by looking at the national health care systems of many leading industrial nations, particularly how they pay doctors and why medical malpractice is a non-issue. These nations provide better health at half the cost.
Meanwhile, I continue to search for answers while my patience, resolve and check book wear thin. In the mean time, last week I saw the neurosurgeon again and after stating my back was not in pain for the third time, he announced that no back surgery was warranted.
He finally heard me. Yet, I am walking with a cane.
Pearl Korn is an advocate of improved Medicare for All, the United States National Health Care Act (H.R. 676).
Crossposted with KevinMD.com.
As a candidate for the U.S House of Representatives (IL 15), I'm looking forward to getting to Washington, D.C. next January and helping to push for REAL health care financing reform. I'm also a full-time Emergency Medicine E.D., and I'm tired of bearing witness to all the horrible ways in which our current system malfunctions. We could do so much better, with appropriate leadership in Washington.
David Gill, M.D.
www.gill2010.com
And doctors are so busy, with so many patients (too many), there isn't the time there used to be, in most cases, for indepth consultations, research on the individual patient's medical problem... really spending time getting to understand what is going on. The medical system is at fault. The patient suffers. Alas.
Pearl's problems are not solved after seeing numerous doctors of different specialities. Not all New York doctors and specialists can be bad. So clearly it is not a deficiency of the doctors; who can do the best with what the current state of medical science has to offer.
The likely issues are what this patient like many other patients find difficult to confront and address or accept. So please excuse my bluntness.
1. What is the patient's age?
2. Is she over-weight?
3. Does she have predisposing problems like osteoporosis or osteoarthritis?
4. Does she accept and resign herself to live with her limitations, thus reducing her stress?
So here are my 2 cents. Instead of blaming medicine, the physicians, the fee-for-service system etc. and desiring more and more doctors and more and more tests, please accept your chronic condition and learn to live with the limits of your physical abilities. Many patients likely will find more comfort peace and solace in accepting their situation. Appreciate the many years of good quality life you have lived and enjoyed with the family.
Doctors even in New York City are mere humans. They are not gods.
I don't know if the insurance company or NY ER recommended an Orthopedic Surgeon for follow-up. When I fell and broke my kneecap, I was taken to the ER and the Orthopedic Surgeon was paged, surgery scheduled and I went home on the day of surgery. As a healthcare worker, I refused an overnight stay.
Yep, sometimes you have to be your own advocate and be a demanding advocate. You may not win the "best liked" ribbon, but you probably end up with the best care.
Sad part: If you don't know how the healthcare system works, you fall victim to the giant run-around, wasted time and tests and the costs run on and on and no real healthcare.
They do more research buying a washer than their doctors. Stop being so lazy.
Find out where they went to med school, Where did they do their internship, did they do a fellowship?
Since you live in New York - you should have done your research and gone to New York Hospital of Special Surgery (no. 1 orthopedic hospital in the US)
First clue you went to the wrong doctor if he gave you a cortisone shot (no one does that anymore- it masks the pain and the symptoms)
And Pearl -The VA hospital system is horrible ( i know from working in one) These are docs who only want to work 8-5
The salary doc idea attracts very lazy doctors just like the HMO like Kaiser
The care given to our vets in atrocious and shameful.
Have you ever been taken care of at a VA Hospital?
If not than I would like to know how you base your thoughts?
I can't stress enough- research your doctors? do you have internet access than look up your doctor
Check out his education
check out his credentials
Check out his health grade
Take some responsibility
Every profession has excellent and not so good whether doctors , mechanics, lawyers, bar tenders, etc.
So don't A SS ume just because you are going to a doctor than they are all the same.
However, I'm not sure eliminating fee-for-service will make that great of an improvement. It reminds when I hired movers. The first time I did it, the movers charged a flat fee. So what happenned was they loaded my things onto a truck with 8 other people, and they tried to shovel off my stuff as fast as they could. I wasn't there to witness everything so some of my stuff got damaged. So next I hired movers on a per-hour basis. They were much more careful, but they did everything they could to slow down and stall as much time as possible. So you pick your poison, and if doctors were salaried, somehow I get the feeling that waits for appointments would take much, much longer, because their incentive to be efficient has gone.
Compounding this is the way insurance companies reimburse -- doctors get reimbursed based on a diagnosis code, rather than on whether they problem-solved to make the patient well. Look at how insurance companies fight tooth and nail against treatments regardless of the outcome. (The push to "evidence-based" medicine, instead of being reassuring, is rather frightening as when doctors' behavior is so tightly controlled, there are no opportunities to develop the evidence that certain things work in the first place.)
Note that the RNs and NP offered practical suggestions -- instead of seeking to blame the patient (author).
"If you want me to work for a Government Salary, the result will be I will do as little work as possible."
Here is a person with the unique opportunity to put his talents at the service of another person in order to cure them -- and thus restore decades of human life -- by the early detection and surgical cure of colon cancer.
Would Dr. "chickenNgravy" really want the world to know that his real motivation is simply money?
Of course Pearl Korn has advocated for a single-payer system. Under single payer, medical and surgical care would be publicly financed -- but privately delivered. There would still be fee-for-service!
But she is also correct to cite the VA, for its outcomes (see the book "The Best Care Anywhere") cannot be denied. If there are 2 truly American models for genuine health reform they are single payer (the Medicare model) and the Veterans Administration. Anything less, as we are learning now, is a sham.
Really? So if my doctor wants to sell me his services, and I want to buy them, Pearl Korn, et al, somehow get a say-so in that transaction?
This is surely striping me of a right I currently enjoy, and while I've got no problem expanding assistance for those who need it, I resent my freedoms being taken away by elitists who claim they are doing it for my own good.
Next time someone says that HCR isn't about a government takeover of health care, consider what Korn and many posters here are advocating.
They do more research buying a washer than their doctors. Stop being so lazy.
Find out where they went to med school, Where did they do their internship, did they do a fellowship?
Since you live in New York - you should have done your research and gone to New York Hospital of Special Surgery (no. 1 orthopedic hospital in the US)
First clue you went to the wrong doctor if he gave you a cortisone shot (no one does that anymore- it masks the pain and the symptoms)
And Pearl -The VA hospital system is horrible ( i know from working in one) These are docs who only want to work 8-5
The salary doc idea attracts very lazy doctors just like the HMO like Kaiser
The care given to our vets in atrocious and shameful.
Have you ever been taken care of at a VA Hospital?
If not than I would like to know how you base your thoughts?
I can't stress enough- research your doctors? do you have internet access than look up your doctor
Check out his education
check out his credentials
Check out his health grade
Take some responsibility
Every profession has excellent and not so good whether doctors , mechanics, lawyers, bar tenders, etc.
So don't A. SS ume just because you are going to a doctor than they are all the same.
That said, you can't hold up VA system as one of efficiency. As a resident, we basically ran the VA Hospital. Every six weeks we would change services, (General to Vascular surgery), and the big trick for the chief resident was to delay care of the sickest, most complicated patients and hand them off to the incoming resident, and make it their problem.
I also worked in England, and could go on for pages on that fiasco.
As a surgeon, I do approx. 10-15 colonoscopies every Wednesday. I have done over 5,000 with a single perforation, resulting in a 2 day hospitalization. This is well under the National Average. I have done 1,000 Laparoscopic gallbladder surgeries without a bile duct injury or bleeding complication. Again, well under the National average. I have performed 600 inguinal hernia repairs with one recurrence. WAY, WAY under the National Average.
So, my option is, continue to be successful, because I do a good job. Docs refer to me and patients want to see me. I am completely independent and can choose to work 8 hours a day or 16 hours a day. The other option is to become a Government employee. Because of my demonstarted success, the Government will re-imburse me 2% more than the surgeon down the street, who doesn't fare so well. No thanks!
The only difference would be a doc, say an oncologist, that owns equipment, such as a PET scan and thus makes money for each PET scan that he orders. And, yes, I have seen that exact scenario.
Usually, if I perform a procedure (skin lesion removal, colonoscopy, hernia surgery, Gallbladder surgery) it is because an FP or IM doc referred the patient to me for that procedure. I don't turn around and give them a kickback.
If any doc tells you that surgery is required and you don't know exactly why, what is to be done and what the risks/benefits are, that is your own fault. I don't understand Pearl's doc telling her she needs back surgery when she has no back pain. Ask him why? Then tell him no thanks.
If you want me to work for a Government Salary, the result will be I will do as little work as possible.
ha
stupid americans!