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Viewpoint: Good, not-so-good changes face doctors, patients today


The world of medicine is changing quickly.

The medical field keeps changing. Many of the changes are advertised in the name of quality but seem to be for the financial benefit of the insurance companies. I applaud the changes that improve care and outcomes for patients, but I dislike the ones that decrease the time we physicians get to spend with our patients because we are busy documenting the medical record so we can get paid.

I have participated in the delivery of healthcare in one form or another since 1968, nearly 45 years and counting. My parents knew I was interested in the medical field, and they encouraged me to get my feet wet after they noticed a poster recruiting volunteers for a local hospital. Initially, I was a “candy striper” volunteer in an emergency room (back when we called them the ER instead of the emergency department, or ED). Other changes:

Medical technology training. My first paid employment at age 16 was at the same hospital as a phlebotomist. At age 18, I again received on-the-job training to be a medical technologist in another hospital’s clinical chemistry lab while I attended college. These days, you have to attend a college program in medical technology and pass a certifying exam to get such a position.

Allied health credentials. I attended one of the early physician assistant (PA) programs when they certified graduates after 24 months of intensive training. Now, they award a master’s degree. I suspect a doctorate is just around the corner, in keeping with several other allied medical professions, including pharmacists, physical therapists, audiologists, nurse practitioners, and others.

Payment models. In the 1970s, most healthcare was paid for using a straight fee-for-service model. I was a patient of one of the early (staff model) health maintenance organizations (HMOs) in the 1980s. Expansion of managed care and HMOs, with networks of participating physicians, grew exponentially in the 1990s, when we also experienced a spike in the capitation (or decapitation, as some of my colleagues referred to it) payment model.

Hospital payments from Medicare have evolved as well. Diagnostic related groups, via which hospitals get paid by diagnosis instead of length of stay, and an all-inclusive prospective payment system for skilled nursing facilities based on the reimbursement utilization groups, changed the way both of those institutions look at reimbursements.

The decade beyond has brought us electronic health records, the Affordable Care Act, meaningful use, and accountable care organizations.

Practice settings. After 4 years of practice as a PA employed by a family physician, I enrolled in medical school and then completed a residency in internal medicine. When I graduated, primary care physicians (PCPs) routinely took care of their own patients at the office, hospital, nursing home, and, sometimes, in patient homes via house calls. I have not changed much in this regard, but these days, most PCPs only see patients in an office setting. But what could ever be a more “meaningful use” of PCPs than having them see their own patients in their offices, hospitals, and nursing homes as opposed to the more modern practices that fragment a patient’s care among different providers in various venues?

Patient financial obligations. More and more patients are being held responsible for increasing portions of their medical expenses. This accountability can take the form of paying a larger share of a health insurance premium that in the past may have been completely paid by an employer, or being responsible for a larger deductible.

Many of my patients (and my own family) have had family policy deductibles of $3,000 to $6,000 per calendar year. Some folks can pay such amounts with pre-tax dollars using a flexible spending account or health savings account (HSA). Often, an employer may contribute some money to an HSA, but for the biggest portion of the expense, a patient has to earn the money and fund the HSA himself or herself.

Operating room (OR) time and insurance deductibles. “Holidays ruin the practice of medicine,” I recall one of my early mentors exclaiming. He was an otolaryngologist, and he clearly was upset about holidays that fell on weekends being celebrated with a 3-day weekend extending to Monday, thus eliminating his reserved elective OR schedule block on some Monday mornings.

In many hospitals, reserving blocks of OR time has been replaced by a first-come, first-served system. Over the 45 years I have been delivering medical care, I have observed that most patients cherish the holiday season each December. They try hard not to schedule any elective medical appointments starting the week before Thanksgiving and extending until after New Year’s Day. This past year was different; deductibles have become a larger factor in patients’ medical decisions.

Case #1: An otherwise healthy woman has a shoulder injury in September. Orthopedic consultation and a magnetic resonance imaging scan reveal a diagnosis of a rotator cuff tear.

Conservative therapy, with physical therapy and a steroid injection, are ineffective. The patient continues to experience some pain.

She sees the orthopedist again shortly before Thanksgiving, and surgery is scheduled for mid-December with the anticipation of the usual postoperative recovery period.

The planning for a large family gathering around the December holidays has been in the works for weeks. The patient says to her husband: “I can take the pain a few weeks longer. Let’s postpone the surgery to January.” The husband replies: “No. We already met our deductible for this year. Let’s get it done now so it will be covered.”

Case #2: An athletic man who cherishes his weekly tennis game comes into the office in mid-December for a preoperative physical examination so he can be cleared for shoulder surgery that is scheduled for the last week of December. His wife had several medical expenses earlier in the year, so the family already has met its deductible. During the preop exam, the patient mentions that he experiences attacks of right upper-quadrant pain that radiates to his right scapulae after eating high-fat meals, and he wonders whether he might have a gall bladder problem. He is asymptomatic with regard to the gall bladder at this time.

An ultrasound performed the day before Christmas confirms gall stones. The patient is advised that he should follow a low-fat diet and have a cholecysectomy when he recovers from the scheduled shoulder surgery, after which his arm will be in a fixed position in a sling across his chest for 3 to 4 weeks. He asks: “But Doc, can’t they do both operations at the same time? We already used up our deductible for this year.”

I have observed that some patients with higher deductibles are a bit more savvy and act as informed consumers about how their healthcare dollars are spent. They use some of the health expense calculators available from their insurance companies or the Internet, ask for prescriptions to be generic, and ask how much laboratory tests and x-rays cost before they agree to undergo them. Most patients with higher deductibles spend much of their time worrying about how they will pay their deductibles or fund their HSAs and often forgo certain medical care to reduce expenses.

Technology in clinical medical education. As an assistant clinical professor of medicine at the University of Connecticut School of Medicine, I am a one-on-one mentor of sorts to medical students in the Student Continuity Practice. Students are assigned to the practice in October of their first year of medical school and come for half a day each week for a mandatory 3 years. The fourth year is optional.

I frequently ask students a question about a clinical matter that presents in the office. Formerly, if they did not know the answer, they would go home or to the medical school library that evening and read about the pathophysiology and clinical aspects of the subject matter in a standard textbook of internal medicine and report back to me the next week. Now, the students whip out their smartphones and “Google” the subject and know the answer before they even move on to the next patient.

Those are just some of the ways I’ve found that the medical field is changing. What has your experience been? Do you think medicine is changing for the better or for the worse? Or is it just that change is inevitable?

The author practices internal medicine in Newington, Connecticut. From the Board columns reflect the opinions of the authors and are independent of Medical Economics. Send your feedback to medec@advanstar.com.


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© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health