The crisis in US medical care: A doctor’s perspective

My name is Scott. I am a physician. Specifically, I am an anesthesiologist, practicing in Florida. Medicine has changed a lot during my 40 years in practice. In fact, we all know it is broken. The problem is how to fix it. As an “insider” I can tell you none of the recent solutions will work. The system is just too complicated. Each aspect of medical care is intertwined with others. Medical decisions are influenced by multiple factors: insurance company authorization, oversight by State and/or Federal agencies, medical malpractice insurance company guidelines, reimbursement concerns, hospital administration concerns, defensive practice in today’s litiginous society, Emergency Room overload, medical society ‘best’ practice guidelines, cost of care and unfortunately, last on the list is the patient’s well being. Here is a “simple” example:

A patient comes to the Emergency Room. The reason may be an actual emergency, or may not be an emergency, like it’s after hours for their family doctor, they don’t know where else to go or they don’t have insurance. The ER doctor knows if he or she doesn’t diagnose the problem correctly he/she and the hospital may be sued. So, every test in the book is ordered. If anything is abnormal, the patient gets admitted. One admitted, the hospital is responsible for treatment - whether the patient has insurance or not (i.e., whether the hospital will get paid or not). Their own family doctor doesn’t make rounds in the hospital anymore, so the patient is admitted to the hospitalist on call (a primary care physician hired by the hospital). The clock is now ticking because the hospital gets paid a fixed amount by Medicare or Medicaid based on the diagnosis only (most of the ER admissions are Medicare or Medicaid here in Florida, although many insurance companies are following the government lead and also reimbursing by diagnosis only - called a DRG, diagnosis related group). So, although the hospital bills a HUGE amount to the patient, they actually receive a small amount, according to the DRG. A self-pay patient (no insurance) generally can’t afford the full price billed to them and works out a deal to pay $10 a month, for example. In reality, they wind up rarely paying for their treatment.

But I digress. Back to our “simple” example. Here’s the next problem. While the hospital gets paid a fixed amount, hospitalists get paid by the number of days they care for a patient. Their incentive is the opposite of the hospital who is ‘on the clock’ payment wise. In fact, each DRG has an associated LOS (length of stay). If a patient stays in the hospital longer than their LOS, the hospital’s fixed DRG payment gets cut a certain percentage. So, after the hospitalist studies all the tests and gets numerous consultations from specialists for 3-4 days (their payment starts to get cut after 4 days), they refer the patient to a specialist (e.g., a surgeon) for definitive treatment.

Most of my experience as an anesthesiologist is with surgery. If the patient’s problem is surgical, the surgeon (specialist) takes over care. Now, the surgeon knows he can’t let a patient go home without treating the condition, so he schedules surgery. After surgery, the surgeon is pressured by the hospital to get that patient out of the hospital (remember, the hospital is running out of LOS days and can’t afford to lose money). There is a whole department of nurse/administrators (case managers) whose only job is to keep track of LOS and push for a discharge or look for legitimate reasons to appeal for additional LOS days. Often, a patient is discharged before they are truly ready due to LOS payment issues. This is one reason a rehabilitation facility may enter the picture. Patients who can’t take care of themselves after discharge go to one of these because there is different payment available for rehab. This is also where there is opportunity for an attorney to convince a patient he or she was not treated properly and can sue their physicians and hospital. But that is another story for another time.

In the “good old days” of medical care, a person with a stomach ache went to their family physician. Let’s say a gallbladder attack was suspected. Tests would be ordered (specific for gall bladder disease) and done as an outpatient (less expensive than in the hospital). If positive, the person would be referred to a surgeon who would schedule surgery (again, as an outpatient, less expensive) and the problem gets treated.

Today, once that same patient goes to the ER, it’s a different story. Many hours of agony are spent in the ER waiting to be seen and waiting for a host of test results. Several days are spent in the hospital, still in pain, until surgery is performed. The net result is the same, but with a lot more time spent, with a lot more pain endured and with a lot more cost.

Most people don’t understand what is happening within the world of medicine. I feel too many people who aren’t doctors are making decisions affecting the practice of medicine and ultimately will destroy it. Yes, it needs to be fixed. But, it needs to be fixed properly and that can only be accomplished through understanding what the problems are. In my small way, I hope I can help fix things by spreading understanding. This article is only a small peek into my world. It’s the tip of the iceberg, if you will. So many factors, some listed above, affect how medical care is delivered and, ultimately, the health of every individual.

If this article is interesting to you and you want to know more, please consider upvoting it. If there is enough interest, I will continue with more articles that will explain the above in more detail and explore other medical issues.