History and Physical on the State of American Medicine

Chief Concerns:

• Impairment of the doctor-patient relationship by extensive intrusion from third party payers.
• Meaningful use criteria and the huge financial incentive, coupled with physicians being driven into employment, resulting in severe degradation of the medical record.
• Health insurer monopsony behavior (control of a market by a small number of buyers).

History of Present Illness:

World War II wage controls resulted in employers looking for alternative benefits to attract employees. Health insurance began to be offered, and proved popular. The McCarran-Ferguson Act exempted insurance from antitrust law. When the IRS realized that employees were receiving this substantial benefit, which was not being taxed as income, it sought to collect. The resulting outcry caused Congress to make health coverage bought by employers (but not by individuals) tax exempt; according to Milton Friedman, this is why the health insurance market developed differently from the rest of the insurance market. The rise of third party payers with deep pockets initially resulted in a windfall for doctors and hospitals. They could perform most any service, and be paid essentially what they billed. There were multiple factors driving increases in the services provided, and thus the expenditures. Defensive medicine due to frivolous lawsuits, including failure to provide every conceivable test and treatment at end of life, either demanded by patients and their families, or not desired by them, but prescribed by their doctors, out of fear of potential liability, or discomfort and inadequate training in discussing end of life matters, leading to continuance of tests and treatments beyond their usefulness, or simple greed. Costs spiraled out of control. The payers saw that they could not simply give the doctors and hospitals a blank check, so they began to discount the charges billed to them, and to control physician practice. Because the law said that charges to self pay patients had to be the same as charges to insurance companies (otherwise, it was considered "fraud"), even though the companies would invariably diminish the portion they would pay of the bill significantly, while most private persons try to pay what they are billed, self pay became even more unaffordable. Billing and regulations became more complex, until 31 cents of each healthcare dollar was spent on dealing with them. There are 2.2 billing personnel for each physician now.

• Health insurance companies acted more and more like legal monopsonists. Became steadily more intrusive. Forced contracts and "credentialing" due to this power. Unilateral fee setting, while forcing bills to self pay patients to remain high. Smaller/private practice largely driven out of business, and forced into employment.
• Electronic health record companies lobbied heavily for complex, expensive mandates with the 2009 HITECH/meaningful use of EHR committee (23 members, 9 of whom were physicians, 2 of these were practicing).
• The ultimate impact of the Affordable Care Act is not yet clear to me.

Physical Exam:

Doctors are being driven from private practice into employment by the forces noted above, along with tremendous imposed regulatory and financial burdens (Medicare regulatory code 130,000 pages. For comparison, the IRS tax code is 75,000 pages. Implementation of ICD-10 coding changes, imposed by CMS, will cost each practice between $22,500 and 105,500, according to the AMA). Employers, keen to collect the 20+ billion dollars allocated for "meaningful use" of EHR, are turning physicians into "providers" of data. They are forced to concentrate on their computer screens, as the medical encounter document, not the provision of medical care itself, has become the product being sold. Third party payer "prior authorization" requirements for even routine medication prescriptions as well as many tests, has resulted in experienced clinicians playing an endless game of "mother may I?" with insurance companies, often having to obtain an authorization to proceed with their plan of care from persons not specialized in the area of care in question, or without any clinical training at all.

Data and references:

1. "How to Cure Health Care" Milton Friedman, Hoover Institute. 2001.
2. Health Care and Medical Liability Reform: Perspectives from a Doctor-Lawyer Interview with Donald Palmisano, MD, JD, former AMA President. Modern Medicine. April 27, 2010.
3. Testimony before Congress. Dr. Danielle Martin, 2009.
4. "Health Reform and the Decline of Physician Private Practice" Physiciansfoundation surveys. 2010, 2012.
5. "A Digital Shift on Health Data Swells Profits in an Industry". Julie Creswell. NY Times. February 19, 2013.

Assessment and Plan:

Compromise of the doctor-patient relationship

Doctors, like pilots, must be captains of their ships, and have final authority in patient care decisions regarding the patients they are attending (this does not mean they can defy the laws of economics, any more than pilots can defy the law of gravity). If someone else wants this final authority (CMS, insurance, administrators), then they need to SIGN their orders and take responsibility for their decisions. Note that making diagnostic and treatment decisions on patients without seeing the patient personally, and having a license to do so, constitutes malpractice and/or practicing without license. Doctors who sign medical documents which do not accurately reflect the patient encounter are committing fraud. Legal remedies will apply.

"Meaningful Use" and the degradation of the medical record

Immediate halt to implementation and payments pending studies addressing effectiveness and impact on patient care. Collaborate with National Nurses United and other clinicians calling for the same. Meanwhile, doctors will document their encounters electronically as they see fit, by dictation, typing or template.

Third party payer monopsony

Call on the Federal Trade Commission to investigate such actions, under the McCarran-Ferguson Act clause regarding cases of coercion. Repeal McCarran-Ferguson, or give doctors the same antitrust exemption. End employer provided healthcare tax exemption or grant same to individuals. Require insurance company personnel questioning medical decisions on individuals to be licensed to do so and of the proper specialty. They must review the chart, then speak with the ordering doctor if necessary, then examine the patient if they still disagree.