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Monday May 22, 2017

It's Complicated: What We Wish Legislators Knew About Health Care

Editor's Note: Health care is complicated, considerably more than some people realize. With hundreds of family physicians advocating for our specialty on Capitol Hill this week during the Family Medicine Advocacy Summit and the Academy promoting family medicine with a social media campaign, we asked our new physician bloggers what they wish policymakers knew about health care.  

Kimberly Becher, M.D.
Federally qualified health center (FQHC), Clay, W.V.

As physicians, we hear stories about people's lives that no one wants to talk about publicly. We discover embarrassing facts that no one would want to share in a Senate hearing.

Matt Northam photo(creativecommons.org)

I have a patient who worked full-time manual labor for decades. With no health insurance, her chronic obstructive pulmonary disease progressively worsened. She would stumble into my office with oxygen saturations in the 70s. I tried to find a way to get her oxygen, but financially we couldn't do it. Eventually her condition caused heart failure and she ended up in the ER, the last place she wanted to be. At that point, she had to be honest with me. She had no electricity and therefore wasn't able to use the nebulizer treatments I had been prescribing. This person was working full time at a minimum wage job, yet she will die sooner because of her commitment to this job.

If legislators were aware of scenarios like this when considering health care policies, would they make decisions that would prevent such outcomes?

Natasha Bhuyan, M.D.
Employed physician, Phoenix

I wish legislators understood primary care. A failure of primary care drives up costs. A failure of health care access means patients wind up in the emergency room unnecessarily. A failure of continuity means fragmented care and duplicate tests, resulting in $200 billion in health care waste. A failure of comprehensive care shuffles patients to too many subspecialists. And a failure of care coordination leaves patients confused, frustrated and deteriorating within our mammoth health care system.

Primary care doctors are expected to succeed in all of the above while advocating for our patients, completing prior authorizations, calling subspecialists, staying current on medical practice and much more. We do all this in a broken system that invests less than 8 percent of spending on primary care.

I wish legislators knew that unless we begin to invest appropriate resources into primary care, our system will collapse.

Kurt Bravata, M.D.
Employed physician, Buffalo, Mo.

When I was going through medical school and residency, I heard countless versions of "Treat the patient, not the computer." However, each new legislative action or quality improvement initiative seems to push us further away from personalized patient care and closer to a numbers-only model. Health care should never be treated as a zero-sum game. High patient satisfaction and good metrics scores don't always correlate with good patient care. Physicians and institutions may respond to such pressures by selecting their patient panels to meet the metrics. In so doing, patients fall through the cracks of a system that prioritizes churning out quantifiable outcomes data in short intervals over improving a patient's health through slow and steady guided lifestyle modification.

Our altruism, training and finely honed instincts can often -- through the natural process of building relationships -- produce results over time that won't always show up on quarterly score cards. As physicians, we care more about real people than the numbers that have come to represent them. Legislation should empower physicians to do our jobs the way only those of us in the field can.

Luis Garcia, M.D.
FQHC, York, Pa.

The other day, surprisingly, I had enough time to speak to one of my diabetic patients about nutrition. I went through my usual routine of listing all the different kinds of carbohydrates that would elevate his blood sugar, and gave examples of healthier food options that would help bring down his A1c. Since his diet consisted mainly of rice, beans and meat, I gave him a few examples of vegetables he could try. He stopped me when I said "asparagus" and asked, "What's that?" I showed him a picture on my computer, but he still seemed confused.  

Many of our patients don't know how to live or eat healthy, and many of those who do struggle to afford it.    

Our legislators need to realize that changing how the country covers health care costs doesn't fix our nation's poor health. As a country we are sick, and if legislators don't push to improve the health of U.S. citizens, we will never get better.  

Melissa Hemphill, M.D.
Family medicine residency faculty, Portland, Ore.

I wish lawmakers understood the burden of medical school debt and how it affects the health care workforce. We need more primary care physicians, especially in rural and underserved areas. Unfortunately, debt drives doctors away from both.

The average medical student graduates with nearly $180,000 in debt(members.aamc.org), a sum that inevitably influences specialty choice, practice type and job location.

I often hear my residents say that they must choose a safe job with a salary guarantee so they can pay their loans. More doctors are joining large, urban employers instead of moving to rural areas, working in FQHCs, or hanging their own shingle in private practice somewhere they are desperately needed.

With federal loan programs like the Public Service Loan Forgiveness program under scrutiny(www.marketwatch.com), residents and recent graduates feel more uncertainty than ever. Residents doubt they will be able to pay back loans, afford a house or save for retirement. That insecurity is a major trigger for burnout, makes many question if practicing medicine is sustainable and could shrink our workforce.

Primary care providers are an essential part of healthy, resilient communities and economies. I wish lawmakers would enact policies that make it easier to become family physicians and to work in underserved areas.

Ryan Neuhofel, D.O., M.P.H.
Direct primary care practice (DPC) owner, Lawrence, Kan.

I'm not sure policymakers realize that coverage alone does nothing to improve the fundamental problem of the high costs of care. There are fewer uninsured people, but the cost and hassle of obtaining routine care have continued to rise for most patients. I routinely meet patients who wrongly assumed their new insurance plans would cover what they needed but find instead that they are stuck with enormous bills for relatively minor health issues.

Two new patients of mine come to mind:

  • A patient with uncomplicated, well-controlled diabetes (only on a metformin, lisinopril and simvastatin) who paid nearly $3,000 per year for his meds, basic labs twice yearly and a couple of doctor visits
  • A 27-year-old who paid $7,000 out of pocket for the management of a simple forearm fracture

Both of these people used their respective insurance network of providers as policymakers intended before they found my DPC practice.

The total cost of annual membership in my practice (which covers all clinic visits and communications at no additional cost), plus the price to provide the same care to these two patients for the conditions mentioned above would have been far less than $1,000 each. Even before you consider that my patients are getting unlimited primary care with our fees, the contrast is staggering.

Beth Oller, M.D.
Rural practice owner, Stockton, Kan.

I wish policymakers understood what poor insurance coverage for the working poor and cutting programs such as Planned Parenthood means for millions of patients. I care for many pregnant women and young children in my practice. My first encounter with a patient often occurs when she comes to establish OB care, and often it is with an unplanned pregnancy.

Since the local Planned Parenthood closed two years ago, there are many women in my rural area without an affordable option for well-woman care, testing for sexually transmitted diseases and contraception. I will see patients for extreme discounts with proof of income, but I don't have any control over what labs or pharmacies charge. Although oral contraceptives are generally affordable, it is also easy to miss a dose. Many women would prefer long-term contraception, but without a clinic with Title X coverage in the area, this option is prohibitively expensive.

These women can get coverage while they are pregnant and for a short time afterward, but they frequently have difficulty affording care as soon as this coverage runs out. This leaves women without coverage to take care of post-partum issues such as breastfeeding support, postpartum depression and anxiety, and continued well-woman care. We try to get long-term contraception placed while they are still under the coverage period if appropriate so at least that is covered.  

Marie Ramas, M.D.
FQHC, Nashua, N.H.

I wish policymakers understood that mental health care is not an option, but rather a necessity to build healthy populations. The CDC notes that between 2005-2006, one in 20 Americans age 12 and older were depressed(www.cdc.gov). At my FQHC, I see the effects of untreated psychiatric disorders, ranging from missed work days to heart attacks due to lack of supportive services to deal with stress.

After the passage of the Patient Protection and Affordable Care Act, I noticed an increase in patients who were able to obtain medications for psychiatric disorders as well as new patients who had been able to acquire insurance despite pre-existing psychiatric conditions. As with all aspects of health and well-being, however, treatment of mental health extends much further than simply taking a pill. It is well known that having access to therapy, regular exercise and support groups can vastly improve outcomes and outlooks when dealing with psychiatric illness. Unfortunately, for many of my working-class patients, these supportive practices are unattainable.

How much better off would we be as a society if we had a true health care system instead of a sick care system?

Venis Wilder, M.D.
Director of quality improvement and medical director for a community health network, New York

It took months to get a confirmed diagnosis and months more to get a treatment plan approved for a patient at my FQHC. Despite a diagnosis code consistent with lung cancer screening and weight loss, a CT lung scan was initially denied by her insurance company. After receiving the denial letter, I was required to discuss the need for specific imaging with the insurance company's staff doctor, who had no familiarity with my patient or her situation. I was forced to order the obligatory chest X-ray. Fortunately, the imaging facility inadvertently completed both tests. The X-ray revealed nothing, but the CT scan showed a peribronchial lung mass.

I immediately sent the patient to a pulmonologist in her network, who saw only the chest X-ray and sent her away with nebulizers. Our electronic health records aren't linked, so the subspecialist depended on the patient and her family to provide information.

I spoke to the pulmonologist to question why nebulizers were given for a malignancy. He saw her again, but the case was beyond his expertise so she was referred to another pulmonologist for reevaluation and a biopsy. Both proved difficult to schedule, and we waited weeks.

Meanwhile, the patient went to the ER twice, the second time for an anxiety attack related to her lack of diagnosis verification and treatment. Finally, I was able to convince a nurse practitioner at the ER to admit the patient so the biopsy could be expedited.

Health care is, in fact, complicated because there are so many barriers to what should be a streamlined process. Varied insurance company restrictions, multiple hospital systems, discordant electronic medical records, imperfect diagnostic testing, patients, doctors and more can prevent patients from getting the timely help they need.

Posted at 04:01PM May 22, 2017 by Kimberly Becher, M.D.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.