I had a great exchange with a physician reader recently about HIPAA and it led to this doctor sharing his story with me. He covered a lot of ground including reimbursement challenges and history, conversations about death, integrative medicine, time spent with patients, medical education and much more.
I love first hand, off the cuff perspectives on the history of medicine and how we got where we are today. No doubt there’s always more to the story, but I think perspectives from doctors like the one that follows helps those of us who work in healthcare IT. It wasn’t intended to published, but that’s what I love about it. I hope you enjoy it as well.
I am originally from Manhattan but have lived in the DC area since 78. Ironically, I have never eaten at the government trough. I have a friend I met during my residency in Baltimore. He retired one year short because the overtime was killing him. He has since worked for Uncle Sam in a number of capacities. When he does retire, he will receive three checks…ah, if I had it to do all over again…when in Rome….
In private practice though, having worked in a number of different situations, I have had patients from every 3 letter agency that you can think of. The public has no real idea how crazy our government bureaucracy really is. The amount of waste is inconceivable. I remember laughing the first time I heard the term “beltway bandit.” Now, banditry has stretched far beyond the beltway.
What concerns me most about American Medicine is the fact that it is a business and big business at that. The problem is that it was doomed from its inception, an unholy alliance or marriage between Flexner, who condemned naturally, holistic remedies, and Rockefeller owner of Standard Oil…think organic chemical manipulation….gave birth to a child named Big Pharma and the genesis of the allopathic (against symptom) approach which has brought us to where we are today.
Add to this the change which occurred when slick surgeons forever tilted reimbursement rates to favor procedures rather than cognition. It was simple, a statistical analysis of the then existing ills that had a surgical solution. Realize that since patients would not be paying out of pocket, drive up the reimbursement for the surgeon performing the procedure. The hospitals followed in turn eventually adding cost shifting to the mix. Eventually, the malignancy spread and cognitive physicians came on board only to see their real income drop because of inflation and the procedural slant to reimbursement.
Let me demonstrate this from my own experience. Let me first digress and explain how I evolved to where I am today. My original training was in Infernal Medicine. I did my residency from 86 to 89 at the beginning of the AIDS crisis. When I started there were no patients. The first was a 7-ish year old guy who died from kidney failure who happened to be demented.
this boy’s diagnosis was AIDS dementia. Hmmm…he was not homosexual. He did however have a transfusion as did what became a deluge of patients, often with strange presentations, like the woman who came in complaining that she had difficulty walking. She had a collection of golf sized balls of lymphoma in her brain which developed because HIV destroyed her immune system, again the result of a transfusion. By the time I left, the place had become a war zone. My job became shepherding people during the transition from life to death.
Eventually, this and other experiences led to my becoming a champion of death. We spend more money on medical care in the last six months of our lives than during the entire time prior to that! Of course medicine should strive to preserve life. However, there comes a time when we have to die and prolonging it I think is a crime.
During my residency I developed a routine when an elderly patient came in who was obviously at the end of his or her life. Yet, some family members would demand that “everything be done.” I would escort the entourage to the ICU where I could always point to at least one poor soul intubated with numerous tubes either going in or out of body orifices or cavities. I would tell the group that ultimately, this is what you will make me do to your loved one. As a result, I almost always was able to get permission for a DNR or do not resuscitate order.
Yes, we live longer. However, what is the point if our final years are compromised by chronic degenerative illnesses: diabetes, Alzheimer’s, and arthritis to name a few. Contributing factors are poisoned air, soil mineral depletion resulting in food that is less nutritious, and the countless FDA approved poisons that we ingest with every bite…yes, those names you cannot pronounce.
Sorry for the digression. After residency, I fell into a Medical Directorship of a substance abuse program. Seeing the mess of Addiction Medicine, the eclectic, empiricist that I am, led me in 1990 to the South Bronx where I spent a few weeks with Dr. Michael Smith of Haight Ashbury fame, learning auricular acupuncture to treat addiction.
This turned into a year long course in Acupuncture. Thus began a journey that took me from conventional western medicine modalities to biofeedback, audio-visual entertainment, cranio electrical stimulation, nutrition, hypnosis, herbal medicine, chiropractic, off label use of pharmaceuticals, a stint as Medical Services Director for the Life Extension Foundation, stuff now under the rubric of complimentary or integrative medicine.
Now to that point regarding cognitive/procedural differences. I spent almost three years working in an undeserved area in rural TN. I had already broadened my skills by working in Urgent Care Centers. In addition to the diagnostic skills of an internist, I was now doing family medicine including pediatrics, gynecology, as well as many Urgent Care procedures. However, to better serve my patients I needed to do more. I added more cardiology service by doing my own stress tests and echocardiograms. (This required training.) An opportunity arose where I could learn to do upper and lower endoscopies. These procedures are generally done by GI docs. I could never get privileges to do these procedures in a major metropolitan area because there are so many specialists. However, in an undeserved area it is a different story. Of course initially, just as I would have done had I trained in GI, I initially did my cases with the assistance and guidance of a GI doc.
Here is the point regarding reimbursement. In my TN private practice I spent at least an hour with all my new older patients. (Eventually, my initial visits would become three hours.) Medicare would reimburse me around $90. With a 50 percent overhead, I was making $50 an hour. However, when you consider all the time that I spent on paperwork, phone calls to or about patients for which I was not reimbursed, it is even less, far less.
However, when I did a colonoscopy and removed a polyp, while I don’t remember exactly how much Medicare and other carriers reimbursed me because it has changed so much over time, but for around a half hour’s worth of work, I received on average between 3 and 5 hundred dollars. The point is that reimbursement has always favored procedural over cognitive medicine. The problem is that everything is backwards. The word doctor comes from the Latin, docere, to teach. That is exactly how I came to see a large part of my role as a physician. The idea is to prevent disease, essentially to put myself out of business which seems counter intuitive. During my time studying acupuncture I had heard, although I was never able to find references to support it, that Chinese physicians at one time were paid only when the patient was well.
When Stark II was passed, all my alternative colleagues who were doing certain things for which insurance would not reimburse, found that they had to drop out of Medicare and other insurance carriers. Combined with the fact that I was seeing very complicated patients and holistic approach, I found that I needed around 3 hours to do an initial history and exam. This was 1995 when I was a beta site for a DOS based EMR which was pretty sophisticated. Personally, I think any less time constitutes malpractice.
I also realized that the American Business model does not select for the right people to become physicians. The truth of the matter is that the best physicians I have known and with whom I share this; that we are all a little bit nuts and that we never cared about money. Our staff were always pushing us to hurry up and stop gabbing with our patients.
You simply cannot practice medicine in an 8 minute encounter. It just does not work. Look at an old Oxford or a Webster’s dictionary and you will find that there are only three professionals, the Clergy, Law, and Medicine. Why? Because they are “callings.” You truly, from the bottom of your heart and in the depths of your soul, care about people. It is impossible for you to see them as your pay check. My patients always had my home number and could call me at anytime. They never abused this. They were always welcome to bring me articles. I had absolutely no problem telling them that I did not know something or that they told me something that I did not know. That is why it is the practice of medicine.
So, the truth is, you have to be a little bit crazy but that is the passion, the essence of a calling, or at least the way I believe it is supposed to be. The American Medical Business model is antithetical with respect to this concept and as such I believe dangerous to your health. So, in my world view, HIPPA is a costly infringement on my ability to care for my patients and as such, potentially harmful to their health.