Why Won't Your Doctor See You Now?
Case #1 - Episode 3 - Reasons Seeking Medical Care Is Challenging
THE PATIENT JOURNEY
The 24-year-old with urinary symptoms was not able to see her physician when she first called, but after OTC treatment recommended by her pharmacist failed, she called back and because of a cancellation, got an appointment with her doctor. Her doctor performed a urinalysis and confirmed that she had a urinary tract infection. He prescribed trimethoprim-sulfa combination antibiotic. Her symptoms resolved quickly.
Why the delay in seeing her doctor when she was ill?
When the patient initially called for an appointment, it’s unlikely her physician or staff was even aware of the call. Currently, 70% of physicians work within large health systems where appointments are managed by a pool of receptionists for efficiency. Non-clinical supervisors, who adhere to rules set by administrators, oversee these processes. Administrators, in turn, follow output objectives set by their managers. As management layers increase, the emphasis by upper management shifts away from doctors and patients and towards productivity and profitability. At the highest levels of management, clinical knowledge is minimal if it exists at all. In “Big Health,” the patient and doctor are largely irrelevant to many of the processes like appointment scheduling. Why aren’t patients seen in a timely fashion?
Anecdote:
In my first practice, if you called my office, it was usually by a receptionist who picked up the telephone and knew who you were. If you needed an appointment and none was available, the receptionist either “worked you in” by double booking or asked the office nurse to speak to you. The nurse asked me if something could be called in the pharmacy or you could wait until the next day to be seen. Why did small medical offices like mine disappear?
Patients Are Losing Their Trusted, Long-Term Physicians
Thirty years ago, in an effort to control healthcare costs, insurance companies expanded from offering only hospitalization insurance to full coverage of doctors’ office visits and medications. After an office visit, instead of having the patient write a check, doctors had to submit a claim to the insurance company in order to be paid. This also required detailed documentation be completed to prove what care was rendered. Each element in the note is counted and the doctor’s pay determined on a scale of 1 to 5 (Current Procedural Terminology codes 99211-99215). Below is what a doctor’s note might look like for a urinary tract infection before and after adoption of insurance documentation requirements. To any practicing physician the information in each of these documents is identical. The doctor’s time to create each is different.
Insurers told doctors to accept less money because they would always pay the bill (which turned out to be false). They discounted fees until they now pay for about 7 minutes of a doctors’ face-to-face time with the patient. Next, insurance companies stopped paying medical offices with fewer than eight doctors at all. By having lots of patients in a few practices, the insurance company could control enough of a practice’s patients to force cost reductions by threatening to put the practice out of business by sending the patients somewhere else. To reduce drug costs, they stopped paying for expensive drugs. The outcry from patients and doctors forced insurance companies to implement more subtle methods like pre-authorization forms for doctors1 and tiered drug schedules.2 The objective was always the same - increase profits for the insurance company by reducing payments to doctors. It worked until there are no more physician practices to bully.
Battling giant insurance companies over reimbursement became too much for doctors. To make matters worse, insurers “lost” 11% of submitted charges on purpose, rejected claims repeatedly because of coding “errors”, and constantly changed the codes required to make payments. Increasing overhead with decreasing payments and more paperwork affected small practices.
The ‘straw that broke the camels back’ came in 2009 when, in an effort to improve healthcare, the government adopted the Health Information Technology for Economic and Clinical Health (HITECH) Act. It provided financial incentives for doctors to adopt electronic medical records (EMR).3 Additionally, penalties were issued to those healthcare organizations who didn’t implement EMR systems. The well-intentioned effort failed to recognize that EMR systems are not yet ready to be used in the practice of medicine. These systems were designed to submit claims for payment from insurance companies - not help doctors care for patients. EMRs dramatically decreased the number of patients a doctor could see per day because of the laborious data input requirements (clicks).4 Worse, the EMR systems cost up to $70,000 with significant annual technology support costs of $20,000 or more.
Except in rural areas where physicians could counter insurance companies’ cuts because there are no other doctors to see their insureds, many physicians simply went to work for hospitals or health systems. Today, nearly 4 out of 5 doctors are employed by a system. Hence, the origin of corporate medicine and “Big Health.”
Anecdote:
Prostate enlargement is a very common symptom in older men. The code to get paid was 600. Some insurance companies would deny 600, but accept 600.00. Others would deny 600.00, but accept 600.21 or 600.09. All of these codes are clinically treated exactly the same way. Resubmitting the claim four times to get paid $75 increased office overhead because of all the additional billing personnel required. Finally, the insurance companies simply lost claims on purpose. The patient wasn’t responsible because they had paid their premium and insurance companies simply ignored small doctors’ offices. It was clear to our office that we could not survive financially in that environment so we merged with a health system.
“Today We’re Working for the Man” - Roy Orbison
Working for a large health organization presented unique new challenges for doctors. Health systems, like insurance companies, are managed by accountants and driven by profit motives. Hospitals prioritize having doctors admit patients, conduct procedures, order lab tests and X-rays, and refer patients to other doctors within the hospital system. If a doctor does not align with these profitability goals, they risk having their salary reduced by 7-10% annually or facing termination without cause.
Additionally, health systems require physicians to sign “non-compete” and confidentiality agreements. These contracts prevent them from practicing within a 15–50-mile radius of the hospital for 1-2 years if they leave. These routine health system practices require doctors to move with 2 months’ notice or to be unemployed for a year. If they are not rehired when their contract expires (because they did not generate enough revenue), they are prohibited from even notifying their patients. Sometimes doctors just disappear from an office and staff is instructed not to tell patients anything about the physician. To many established physicians, employment by hospitals increasingly feels like indentured servitude.
Opinion:
One of the most profound consequences of healthcare consolidation is the erosion of the personal bond between patients and physicians. In this efficiency-driven system, doctors are perceived by health system managers primarily as assets to maximize productivity and profitability. The primary objective of such a healthcare model is to ensure that a physician’s calendar remains fully booked, thus securing a steady stream of income. Receptionists at the front desk are tasked with filling these schedules, often without considering the needs and preferences of both patients and doctors. Consequently, securing an appointment can be a challenge, with wait times extending weeks to months. For patients requiring immediate attention, the prospect of a timely consultation hinges on an appointment cancellation.
THE PATIENT JOURNEY
The 24-year-old’s initial urinary tract infection cleared but recurred a month later. When she called back, she was told by the pool receptionist that she would receive a call back from the nurse. When the nurse called back at the end of the day, she was given an appointment the next day. She saw a provider she had never seen, she was given an antibiotic, and her symptoms cleared within 48 hours.
Opinion:
Doctors and patients have little or nothing to do with how health care is delivered by large health systems. The doctor-patient relationship has suffered as patients have lost their independent doctors who are now health system employees.
PATIENT ACTION:
Ask your doctor what course of illness you should expect. When will you be well?
Ask your doctor how to contact them if you do not improve as expected.
Tell the office manager if you have problems with how the office works.
PHYSICIAN ACTION:
Are you fully aware of the details of your employment contract with the hospital or health system?
Support the Federal Trade Commission proposal to outlaw non-compete agreements.
How do you effect change in the healthcare system in which you work?
Suggest the practice have a patient advisory board to meet regularly with clinic staff to help improve clinic performance.
Preview:
The next episode examines patient access opportunities via non-visit care, telemedicine and eVisits.
A pre-authorization requires a doctor or staff to call the insurance company, be placed on hold even for hours, answer inane questions about the patient, and get an authorization code that approves the medicine or procedure. The goal is for the doctor prescribe something cheaper that does not require the onerous pre-authorization process. Since initial requests are frequently denied, the doctor must write a detailed letter explaining why the treatment is required.
Tiered drugs are different co-payments for different drugs so patient pays more for higher priced medications. The goal is for the patient to call their doctor and request a lower tiered drug.