I am truly not a political person. When people get together and talk about politics in social situations, I’m usually the one who mentions a couple of salient points to look like I know what I’m talking about, then I either leave the conversation or sit silently and nod my head at others while they argue on. This is one of those times, however, I think it is important that I leave my political comfort zone and speak my piece, not for me, rather for future generations of Americans who must navigate the labyrinth that is the Patient Protection and Affordable Care Act. With President Obama’s re-election comes the cementing inevitability of his signature legislation. Its impact will be widespread and affect future generations profoundly, so I offer my ‘insider’ perspective on some of the most disagreeable provisions.
I come from a family of lawyers yet I married a physician. That makes family gatherings interesting!
He happens to be an Ob/Gyn, so I understand the doctor-patient dynamic from both sides of the street. I accept the fact that physicians need to be held accountable for wanton negligence, however, in the 33 years my husband has been in training and practice, I have never known a doctor, or for that matter, any clinician who didn’t live by the First Rule: Do no harm. It’s a professional imperative, akin to the military code of honor. Which begs the question of why they need to practice so defensively? After all, their professional DNA encodes that they be prudent, analytical and healthily obsessive over quality care for every patient.
Why, then the estimated minimum thirty percent markup on America’s healthcare bill? Answer: The malpractice bar is a powerful and intimidating industry. The threat of litigation hovers over every patient encounter like an unfriendly drone. Thoughts of the menacing humiliation, emotional and financial consequences of a malpractice claim poison a trusting atmosphere from the start. It’s no wonder that many physicians over test and over treat to avoid a medically untrained Monday morning quarterback attorney crying foul. While many suits result in defendants’ verdicts, all sued doctors are forever changed as a result. Just ask one. I’ve heard the stories over and over from the best docs. Thus the avoidance behavior we call defensive medicine.
Missing in the PPACA is meaningful tort reform that would have the impact of significantly lowering the total cost of health care. Now that the “fiscal cliff” is history, a new looming and equally threatening hazard awaits with potentially apocalyptic costs if PPACA’s spending obligations aren’t met with serious fiscal discipline. Meaningful tort reform would certainly contain costs and direct resources to patient care, not a bloated malpractice industry. Yet the PPACA only commits $50 million in grants for pilot projects addressing this enormous problem. Ignoring the large defensive medicine gorilla in the room is a glaring omission and a lost opportunity at this critical time.
Another impediment is the Electronic Medical Record mandate, another government mandate that has evolved through previous legislation, but reaches maturity as the PPACA’s most pervasive provisions kick in over the next couple years. One mandate requires doctors to enter all orders and prescriptions. Another punishes incomplete utilization with lower pay, while rewarding compliance with incentive “carrots”. I hear doctors saying they’re the highest paid, most overqualified data entry clerks in America! Of course the central planners claim all this distraction will improve quality and prevent mistakes. However, these and other bureaucratic distractions simply distract clinicians from the core tasks of analyzing and treating patients’ problems. It is estimated the additional burdens can mean 5-10 additional minutes per patient. For the average doc seeing 20 patients daily, that’s roughly 3 hours a day not taking care of sick people! Since healthcare reform is to provide access to 45 million more patients, doctors need less administrative “noise”, not more. As President Obama likes to say of late, “The math just doesn’t work out”. Throw in an estimated doctor shortage of over 90,000 by 2020, according to the Association of American Medical Colleges, and you can see why doctors appear to be aging more quickly than their patients. I know my guy is.
Finally, the subtlest impact of the EMR is its disruptive effect on the clinician-patient relationship. My physician husband was on the other side of that relationship 15 years ago. Diagnosed with a rare but potentially lethal hormonal problem, Cushing’s disease, he endured two major operations in a 6 week period. Blurry vision developed shortly after the first surgery, and as it turned out was a self-limited problem that resolved. His specialist was utilizing an EMR at the time, and as you can guess, doctors (my husband included) do not make very good patients; they know way too much and tend to think the worst. So he was very afraid of what the long-term medical outcome would be. In context, a specialist focusing on a computer rather than a worried doctor-patient didn’t instill reassurance. It’s not the way my husband relates to patients, nor is it what patients expect. This is the worst unintended consequence of the mandated EMR, and an unforgivable erosion of the sacred clinician-patient dynamic. Instead of the doctor giving comfort in response to a patient’s apprehensive body language, or reading and responding to the emotion in her eyes, this valuable interaction is often reduced to a one way keyboarding adventure. Believe me when I say this; the vast majority of clinicians HATE this and simply want to spend quality time with patients, not cuddling up to a government-prescribed computer program.
Now please, do not take away from this that I am whining about how tough the healthcare profession is. There is also great satisfaction in the field of medicine that never gets told. I will never forget the call I received from Randy in the summer of 1986 at about 2 in the morning. Randy was almost crying with joy as he had just delivered his first baby and at that moment decided it was his life’s calling. What inspired me to write this article was not to point out the tough breaks for the professionals in the healthcare field, not at all.
I am truly and obsessively concerned about future generations of Americans (that is, my kids and grandkids
and YOUR kids and grandkids) and THEIR healthcare.
Because of what my husband does for a living, I have a little inside information about how healthcare is going to shake out for the future, and it is scary. Healthcare reform promises lots of goodies: like addressing pre-existing conditions and mandating medical coverage for adult children, along with loaded benefits for all plans. However, the problems I outlined are only a tip of the iceberg. When I say tip of the iceberg, it’s increasingly clear to ever more practicing professionals and policy makers that this one could sink America’s titanic effort at healthcare reform. I only hope and pray, before all of it is implemented fully, that each “piece” is given a trial run in small healthcare arenas, to see if it truly helps patients receive only the health care they truly need, in a cost-effective manner. Only then do we avoid an entire nation’s healthcare falling into the abyss of spiraling expenses and lower quality care. The only mandates for all patient caregivers should be the one obligating them to care well for patients, not puppets on the government string.