I have written about the quality of care that people in the
US receive, and about access to and the cost of care, but another very important
issue is the actual process of obtaining appropriate care. This is a major
source of frustration for patients and their families, and can drive anger
against the system, against doctors, against insurers, against the government.
People who experience this frustration and anger want it to change, and sometimes
want to lash out, offering an opportunity to be intentionally misled by
influential others for their political ends. The demonization of the Affordable
Care Act (“Obamacare”) is a good example. Obamacare actually did lots of good
things, starting with insuring tens of millions who did not previously have
coverage; it also forbid insurers from charging more to those with pre-existing
conditions, and allowed children to stay on their parents’ plans until they are
26. Actually, it did little or nothing bad, if the criterion is access to care.
A few people saw increased premiums, mainly the healthy young and those who previously
had such terrible policies that they were both cheap and essentially worthless.
While the Republican congress tried to repeal it, it turned out that, surprise,
people would be worse off without it.
On the other hand, frustration with the obstacles to
obtaining appropriate care are real, every day, and in-your-face for patients
and their families. I have recently been experiencing these from the perspective
of the patient (or family) rather than that of the provider, as I work at
getting care for my 92-year-old father. My experience with the provider
perspective helps me to understand the situation from both sides, and hopefully
to try to figure out which obstacles are rational and which are simply
unnecessary.
Let me start by largely absolving any of my father’s individual
providers; all those involved with him – physicians both general and
specialist, physical therapists, and more recently the nurses, social workers,
and nurse practitioners through the palliative care agency – are committed,
caring and hard-working. They do their best to help him, to be available, to
respond when a problem, minor or urgent, arises. However, there are obstacles in
the way. Many services require a referral from a physician, from calling in
prescriptions, to ordering lab tests or x-rays (and getting the results), to
getting physical or occupational therapy, to enrolling in palliative care. While
none of these individually may seem to be burdensome for the doctor, there can
be many for any individual patient, multiplied by the number of patients a
physician sees who need these services. While it is sometimes the specialist who
makes such a referral or fills out such a form, it most often “rolls downhill”
to the primary care provider. That provider has to have a very large number of
patients to get by and make a living, so the phone messages and faxes and lab
results pile up while s/he is spending all day actually seeing his/her
patients. Rationalizing the delivery of care means trying to get nurses or
other staff to deal with as many as possible, but lots of these require a
doctor (or other licensed provider, such as a nurse practitioner) to interpret,
approve, or sign off on. And having more
staff costs more money, and means (particularly for the primary care provider,
whose reimbursement is much lower than for many specialists) having more
patients. Thus, a vicious circle, often compared (from the provider’s point of
view) to running on a hamster wheel; for patients, this often seems like
obstructionism.
Of course, it often is obstructionism, but rarely on the
part of the individual provider. The reason is, unsurprisingly, money. For the
providers of care, or more usually the companies for which they work (whether
for-profit or not), the issue is reimbursement by insurers, including Medicare
and Medicaid. There are rules that must be followed, forms that must be filled
out, referrals that must be signed, and procedures to go through, or payment
will not be forthcoming. And then the provider, whether physician, nurse
practitioner, physical therapist, pharmacist, or social worker, whether self-employed
or working for a company, doesn’t get paid. And, depending on how often this
occurs, will make less, fire staff, or go broke. In addition, insurance
companies themselves often create obstacles to payment (such as the
time-honored one of just refusing to pay the first time or two, because maybe
the provider will give up), but this is more often true for costly surgeries
than lower-cost preventive and treatment services.
To be fair, many of the rules that seem to be obstructions
are not only about saving money; they
are about both preventing fraud and even patient safety. There absolutely are major fraudsters out there, doctors
and home-health companies and nursing homes and every sort of medical support
provider (even hospitals), who try to and often succeed in bilking Medicare
(and other insurers) out of millions of dollars in inappropriate (“do you want
a scooter at no cost to you?” – but someone
else is paying!) or truly fraudulent (there is no patient) care. In fact, some care, even if you want it, even if someone
is willing to provide it (if they get
paid), is not appropriate for you, or your family member. Medicare and other
insurers do set criteria, and require that it be documented. This can actually be
good, not only for all of us as taxpayers but for our health and safety.
But often it isn’t good. It sometimes makes care that is
appropriate, evidence-based, and desired, hard to get. It takes a long time. It
takes lots of phone calls, and hours on hold or waiting for calls back. It has
messages lost in piles, or over the weekend. It should not happen, but it does.
And it is frustrating. The “Triple Aim” guiding progressive health care has
received a lot of attention. It is to deliver high-quality care in a cost
effective manner that is satisfying to patients. To document the last, many
hospitals, provider groups, and companies send out “patient satisfaction”
surveys, which are at best cosmetic and at worst destructive. People don’t fill
them out “right”; they tend to reflect an overall impression that leads people
to mark each of the ostensibly-separate questions “great” or “terrible”. Also,
in forming this global impression, folks understandably often overvalue the
things that they can assess (like the quality of food or attractiveness of the
facility) compared to things that they cannot (such as the actual quality of
care). This is, by the way, where providing good customer service makes a big difference,
and while some places are getting better, the medical care industry is
generally weak in this critical area.
As in almost everything, those with the least get the least.
The uninsured, the poorly insured, and the just poor, provide the least
incentive to providers (getting paid) to meet their needs. Government regulations
that require certain services for Medicare or Medicaid without paying for them
result in greater strain on those providers who provide care to people in these
groups. Many providers, especially in some fields or medical specialties or
geographic areas, try to avoid them. They locate in wealthier neighborhood, don’t
take folks who are uninsured (or on Medicaid, and sometimes even Medicare), or
offer indulgent, wonderful “concierge” services for those who can pay a
significant retainer. Thus works the “market” in health care. A terrible way to
go.
A universal health insurance
system won’t make all these problems go away; even with it, systems can still
be poor, providers can be uncaring. But it will help a lot. Because everyone is
covered, there is no “vendor lock”; the market can function well because people
choose their providers based on service, not because they are forced to because
they are locked in to a limited pool. Information flows between primary care
and specialists and therapists and labs and imaging because if it doesn’t folks
are free to take their business elsewhere. The way competition should work;
competition on providing the best product and service.
And, because we would all be in
it together, in the same system, the most empowered will make sure it works for
them, and thus, hopefully, for us all.
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