With the Republican Senate failing to repeal the Affordable Care Act last week, the administration and Congress should consider paying greater attention to the healthcare problems of 2009.
When I graduated medical school in 2009, as the nation debated healthcare reform and the future of our healthcare system, the main challenges impeding doctors and patients were obvious to me. They included a rigid and perverse physician reimbursement system, a labyrinth of increasingly complicated, costly, and sometimes contradictory mandates and priorities, and a runaway malpractice system.
Medicare and Medicaid have historically reimbursed physicians via price controls, and their main cost control mechanism is to pay physicians less. This reimbursement system creates a dangerous lack of time and resources in the trenches, which facilitate myriad unintended consequences that can jeopardize care and ironically increase costs.
The price controls limit access for these patients, particularly those on Medicaid, which can lead to harmful delays or produce a heavy reliance on costly and overcrowded emergency rooms. Ultimately, the poorest patients with the greatest needs are hurt the most and have the hardest time getting help. A recent review in the Journal of General Internal Medicine found an association between hospital strain and mortality. As such, this unnecessary strain this reimbursement system produces also has the potential to harm the care of all patients.
Studies have shown that primary care can improve quality and lower healthcare costs. But the physician reimbursement system is skewed against primary care. This contributes to enormous time pressures on primary care doctors. Research in the Journal of General Internal Medicine found that the average primary care physician addresses on average 7.1 clinical problems in an on average 20.9 minute visit, leaving just 3.8 minutes per item. This time crunch hinders the ability of patients to understand their disease, treatment course, and follow up. It also impedes prevention and counseling that could facilitate healthy lifestyles and detect serious diseases earlier. This compromises care.
Consequently, fewer medical students are pursuing primary care as a career. This limits the accessibility of patients to our healthcare system. When patients are sick and don't have a primary care doctor to turn to, they must either suffer and see their condition worsen or go to expensive emergency rooms. The primary care physician shortage also limits the availability of counseling, prevention, and other services that primary care physicians offer.
The physician reimbursement system has also historically not reimbursed physicians for non-face-to-face care. In addition to impeding innovation, this unintentionally pushes healthcare services to more intensive and costly sites than necessary. This too limits access to care and contributes to rising healthcare costs.
The regulatory climate of medical practice has become increasingly complex. One-size-fits-all regulations work well for inanimate cars moving down an assembly line. Yet they fail to capture the varied backgrounds, experiences and preferences of living human beings, as well as the possible different responses to different interventions. While a certain degree of oversight is needed to ensure quality and safety, doctors have been spending more and more time on charting, paperwork, and checking off boxes and less time with their patients. Over time, healthcare systems have been forced to devote more time and resources to the administration of medicine, which takes valuable resources away from the practice of medicine.
At the same time, the unpredictability of the malpractice system has led to a constant fear of costly lawsuits, encouraging doctors to order unnecessary tests, consults, and admissions to avoid being second-guessed later in court. This practice known as defensive medicine has been estimated to cost our healthcare system between $100 billion and $200 billion annually.
Years later, now as a practicing physician, I know that the problems of our 2009 healthcare system still exist today. Few, if any, are arguing that these challenges have been resolved. In fact, in many ways they have gotten worse. The problems of our 2009 healthcare system need to be addressed now more than ever, and would go a long toward lowering costs and producing a higher-quality, more accessible healthcare system.
Jason D. Fodeman, MD, MBA is a practicing physician. He specializes in delivery systems and health policy.
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