Alt-Health: Doc in a Box
Doctors have been regarded as superheroes and omnipotent beings, as trusted saviors and givers of life. The doctor has also been reviled as a blood-sucking pill pusher with a luxury lifestyle financed on the back of inflated fees. The truth is that physicians are as varied as the patients they treat … and today, the health system is as likely to jerk doctors around as anyone else.
Over the last 20 years, the landscape of medicine has undergone tremendous change. As of this week, the US population is over 325,000,000. Given the sheer size and complexity of our medical industry, it was inevitable that patient data would become digitized, and nowhere has the transition been more role altering than for doctors. The intent was to bring greater efficiency and perhaps, in the long run, that will happen. But for now, what it is mostly doing is driving the doctors nuts.
I have a friend who has been a medical doctor for 25 years. He had this reaction when asked how the new system affected his job: a mirthless laugh, a shrug, a pause … and, “I’m lucky. I can type really fast.” He also has a medical version of Dragon that can take dictation direct to text. These days, data entry is 50% of his job. He’s gotten good at it. But it’s a far cry from the profession he entered out of medical school.
Back in 1995, establishing a private practice was the goal of the graduate. Primary care doctors were called family physicians or general practitioners. Their time was spent tending to their own flock, and they really got to know patients, often for life. Notes were jotted by hand, charts stored in a stack of metal cabinets with a basket of artificial flowers on top. If you went to the hospital, your doctor went, too. The relationship was one of trust.
It was about 2006 that primary care doctors first started going for employment under larger corporations. Five years later, surgeons began seeking employment at a rapid pace. What caused this migration? Many complicated factors. The advent of computer systems necessitated group support. Fees had undergone radical change; hospital-based physicians were paid nearly 35% more, just for doing the same service as part of an institution. Doctors began wanting to have greater control as a collective group. What scared everybody? Perhaps they could smell The Medicare Access and CHIP Reauthorization Act (MACRA) coming.
MACRA was signed into law on April 16, 2015. This bipartisan piece of legislation essentially turned the doctor’s pay incentive from one of “fee for service” to one requiring MDs to jump through digital hoops. The new Merit-based Incentive Payment System (MIPS) graded doctors on “quality of care, resource use and clinical practice improvement activities.” MIPS punished those who didn’t make the grade, with fee cuts. The intent at first seemed to be one of genuine concern for patient welfare. But how exactly did MIPS measure such a thing?
I asked my friend. “Essentially,” he told me, “it’s by filling up a bunch of boxes so the government bureaucrats have more useless information to store.” The extra work is frustrating for the doctor and of no benefit to the patient. Dropdown menus, text fields and codes create a medical record that is often nothing more than a collection of facts without meaning or context.
Unfortunately, our entire health care system is now geared toward this virtual patient. Somehow, in the drive to encode and streamline the system, the actual human being has gotten lost. Far from being the cause of this problem, physicians feel the loss deeply. Studies have found that doctors forced into computerized data entry have lower levels of job satisfaction and higher rates of burnout.
The once independent doctor has become the scapegoat of the American medical system. As the official legal and regulatory authority, it is now the primary care physician’s job to take on tasks that before went to medical assistants. Doctors can spend hours on the phone coordinating patient care with pharmacists, specialists, family members, social workers and insurers, and they are the ones to take the blame if anything goes wrong. The idea behind this was to get costs down. Unfortunately, while the first tally showed NO reduction in cost, studies did show that during that same time period, the physician burnout rate rose from 45% to over 54% across all medical specialties.
All of this makes it surprising to discover that they are still out there — doctors, like my friend, who are genuinely interested in the people they treat, who look at the individual and believe it’s important to know where the patient is coming from. They do not live by data boxes alone, and many have a surprising lack of ego. One of my friend’s favorite quotes: “I bandaged the wound and God healed it.”
I wish Trump would re-Tweet that one.