On Healthcare

Change.  Well, President Obama, congratulations, healthcare has definitely changed.  And it continues to change.  I'm hopeful, it's for the better, but I'm nervous it's not.  I'm anxious to see where we will be in the next 5 years.

Generally, I try to stay out of the political battlefield.  It's ridiculous that opinions on policy turn friends into enemies, and I'd rather have a friend.  However, unfortunately (or maybe fortunately), because of the career I chose, I've been forced to pay a little closer attention lately.  I've watched more political news and read more on policy than I've ever cared to before.  And I'm still naive.  The more I hear, see, and read; the more confused and frustrated I become on the healthcare debate and on our political system in general.  Why can't it just be simple?  Doctors are expected to talk to their patients somewhere in a grade school level to avoid confusion, and although, we may not always be good at that, it sure beats a 2000 page document written by lawyers (no offense) that we are expected to be "for" or "against" when we vote or at least have an opinion about healthcare reform (whatever that means).  And forget trying to find something that just explains the main points because those cliff note versions are laced with bias and manipulation.  If you find a good "Dummies Guide to Healthcare Reform" let me know.

What I've come to conclude, is that healthcare is going to be different, but NO ONE knows what it will look like regardless of who wins the election and who is making the decisions.  It's just too big with too many cooks in the kitchen.  From my very, very limited view point here's my opinion on healthcare.

The Good:

• Refocus on the importance of primary care.  I'm not just saying that because I'm a family physician and hopefully will reap some benefit (trust me, we are not hurting for business the way it is), but really, it's only what makes sense if you are trying to navigate an ever complicated healthcare system; and not to mention, if you're a pencil pusher it's proven to control cost.
• Encourage efficiency.  This kind of goes along with stressing primary care and patient care management (and to a point implementing patient-centered medical homes).  There is honestly a lot of waste in healthcare.  For example: people coming in for appointments that could have been handled over the phone (i.e. one day of cold symptoms); repeating lab tests because you didn't know the resident physician ordered it 4 hours ago or you don't have access to it after hours; prescribing unnecessary medications; ordering CTs, X-rays, and the million dollar work-up because the patient requests it or we are afraid of getting sued; or keeping a patient in the hospital extra days over the weekend, because they can't get the study they need until Monday or they have to meet the 3-midnight rule to qualify for Medicare's nursing home coverage.  Trust me, it happens every single day, and to avoid it would definitely be a good thing.

The Bad:

• Loss of patient responsibility.  (This is my beef with the idea of a "Patient-Centered Medical Home.")  It's frustrating as a doctor after explaining the benefits of a medication, of losing weight, of checking blood sugars, or of stopping smoking to have a patient come back without doing anything or maybe not come back at all.  It's frustrating and annoying, but soon it's going to make me angry because my paycheck is going to be dependent on how well my patient does.  I will be penalized if their diabetes is uncontrolled, if they don't lose weight, or if they have to go back to the hospital.  Unfortunately, it may come to a point when doctors "fire" patients (and believe it or not, if we jump threw the hoops, we have that "right") for noncompliance because we literally can't afford to take care of them.  In my opinion, it's the physicians' job to diagnose accurately, educate well, and recommend appropriate treatment; but it's the patient's responsibility to do it.
• Entitlement.  I disagree with many of our leaders that healthcare is a right.  Healthcare is a resource, and a limited resource at that.
• Treating based on evidence while reimbursement is tied to patient satisfaction.  There has been a big push in our reimbursement model to follow "evidence based medicine."  For example, when a study of sinus infections finds that there isn't any statistical benefit to starting antibiotics in the first 10 days, then the standard is that we shouldn't prescribe antibiotics in the first 10 days.  That's fine and probably good to have some standards; but it also comes at a time when we are also being scrutinized on patient satisfaction.  So now, that patient with the sinus infection comes in to clinic on day 5 of their symptoms, pays their $35 copay and finds out I'm not going to give them the antibiotic they were expecting.  Their satisfaction with me probably isn't going to be that high; which also is fine and probably good to not be catering to patient's every whim, but ultimately the choice becomes to sacrifice meeting standards or sacrifice my bonus for patient satisfaction.  It's a no win situation.

The Ugly:

• EMR.  If you're in the business you know that three-letter naughty word.  Electronic Medical Records has been the thorn in our side.  Sure, it may be better in the long run, but it is painful!  It's like knowing that being a hundred pounds lighter is good, but exercising several hours every day really hurts (and takes a lot of time).  This is one of those things I'm hopeful we'll be grateful for in the future, but I'm nervous it may become a trap to keep payers' (i.e the government and insurance companies) eyes and ears in the exam room.  It also makes me nervous because of the genius computer hackers out there, but I'm trying to be anxious about that.

I could go on and on and on.  And like I said, I'm not really into politics.  My opinions aren't because of my political affiliation, they are just that - my opinions.  Surely, I have a lot more to learn, but given how rapidly things are changing and how confusing it all is, I'm spending most of energy resisting the urge to just give up and wait and see what happens.