WHEN DID MEDICINE AND BUSINESS GET MARRIED?

It slipped up on me. I guess I missed the engagement party. I thought I was going about my career taking care of patients as I planned to do when I decided to be a doctor. But today I find myself worrying more about whether I’ve met my billing quota and my RVU (relative value unit) target for the month. The relative value unit measurement tells administrators whether we are seeing enough patients, keeping our schedule full.   I don’t blame administrators. They’re cogs in the wheels of a totally dysfunctional system. They are doing what they can to keep our doors open.

When I interviewed for a position in medical school, I was asked whether I thought that medical care was a right or privilege. It was a common interview question at the time, and I had been forewarned that it might come up. I had no hesitation in answering that question though. I felt then, as I do now, that access to medical care is a right, not a privilege. I wonder if that question is even asked anymore.  Apparently, the correct answer at the time was that medical care is a right. However, I don’t see that organized medicine has ever truly supported that philosophy because if they had, I don’t think we would be in the mess that we are in now.

Somehow, insurance companies got involved in healthcare. I also remember that when I first started working and had to pick an insurance plan, I was advised to look for a plan that had the best catastrophic coverage, because that’s what insurance was really for. The idea then is that you could still pay cash for doctor’s visits and medications. We’ve come a long way from that.

Why have we tied the ability to access health care to a job? Until the Affordable Care Act, if you didn’t work, you didn’t have insurance unless you met fairly restrictive criteria for a state Medicaid plan or you were wealthy enough to buy a private insurance plan or just pay for your healthcare.

At one time, healthcare companies were nonprofit for the most part. But now they don’t claim to be non-profit. Let’s look at the salaries of the CEO’s of the top healthcare insurance companies. This is public knowledge. You can find it at fiercehealthcare.com.

 

Humana CEO Bruce Broussard $10.3 million

United Health CEO Stephen Hemsley $14.5 million

Cigna CEO David Cordani $17.3 million

Anthem CEO Joseph Swedish $13.6 million

Aetna CEO Mark Bertolini $17.3 million

 

So these guys are paid millions of dollars to find ways to deny the medications and procedures that your doctor orders. Of course, that is an oversimplification of what they do – but not much of an over simplification.

I find it interesting that patients are so against a single payer system, yet are willing to have their healthcare essentially dictated by an insurance company with a CEO paid 17 million dollars to rip them off. Go figure. By the way, we already have a single payer system for those over 65 – Medicare.

Doctors and the AMA have some responsibility for the negative view of single payer systems. For many years, the American Medical Association very opposed to any single payer system, also called socialized medicine. That really is not an accurate label for a single payer system. The AMA’s stated mission is “to promote the art and science of medicine and the betterment of public health,” (ama-assn.org). However, in my opinion, the AMA sometimes seems more interested in protecting doctors than in the interests of patients. Don’t get me wrong. We all benefit from organizations that protect our interests, but healthcare is not like any other entity. It’s life and death for patients. Sometimes, what is good for doctors also benefits patients, but not always. I’ve never joined the AMA.

In future blogs I’ll take a look at healthcare systems in other countries. I believe in gathering data before judging something as bad or good. No healthcare system is perfect, not the single payer systems (which are not all the same) and not our insurance-driven system.

I would recommend a book coming out on April 11 by Elisabeth Rosenthal, MD, called An American Sickness: How healthcare became big business and how you can take it back. Dr. Rosenthal has been a practicing physician as well as an author. She has traveled widely, and she is familiar with other healthcare systems. I was able to hear her on a podcast, and I’m looking forward to reading the book as soon as it comes out. One of her messages is that patients can have a role in taking more control of their healthcare and dealing with insurance companies. I have found that insurance companies sometimes listen to patients more than they listen to us. They will often say that they’ve denied something because the doctor didn’t provide enough information, but in reality they are playing the blame game. The doctor probably filled out the confusing, redundant paperwork, but the request still didn’t meet the insurance company’s criteria for approval. I’ve had insurance companies refuse a request 3 times because they sent us the wrong form to fill out 3 times.

Don’t forget Dr. Rosenthal’s book coming out on April 11. It should be a good read if you care about our healthcare system. I found it on amazon.com.

And I still believe that in our country access to food, education, and healthcare are rights. How they are used is up to the individual.

 

 

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SOMEONE IN YOUR WORLD IS ADDICTED: OPEN YOUR EYES

In the US Revolutionary War, from 1775-1783 there were 50,000 US casualties.  In the Vietnam War (1955-75), there were 211,454 US casualties, while the Iraqi War, from 2003-2011 resulted in 36,710 deaths and the Afghanistan War, from 2001 to the present resulted in 20,904 deaths (US Military Casualties of War, en.wikipedia.org). Over 40,000 women each year die of breast cancer (Jemal et al. Cancer statistics, 2008. CA Cancer J Clin. 2008 Mar-Apr.).   That’s a lot of mothers, fathers, wives, husbands.   Statistics like that grab us. We’re willing to invest in cancer research and treatment.  We honor our military dead. Yet in 2015 alone, more than 52,000 people died of a drug overdose according to the CDC (Center for Disease Control).  Of those 52.000 deaths, 61%  involved an opiate. Between 2001 and 2014, per the National Center for Health Statistics of the CDC, over 250,000 people have died of prescription drug overdoses. Yet, unless one of them happens to be your son, brother, daughter, best friend, wife, those deaths are largely ignored.

We can distance ourselves from those deaths because “it’s their fault.” After all, “they’re drug addicts.” You don’t see fundraisers for drug addiction treatment or parades to celebrate recovery from drug addiction, at least not very often. Yet, we’ve lost more people to drug deaths (not just heroin, but also prescription drugs) over the last 15 years than we did in the Iraqi and Afghanistan Wars combined, or in the Revolutionary War, and we lost more people in 2015 to drug overdoses than we did to breast cancer. What a tremendous waste.

This is a treatable disease.

 Why aren’t people getting treatment? Only a very small percentage of people with addiction are in treatment. There are several reasons. For one, there aren’t enough treatment resources, and there aren’t enough people who specialize in treating addiction, particularly in rural areas. There is still a lot of stigma and misunderstanding People with addiction are told that they are simply weak-willed, that they could stop if they only wanted to, and they buy into that. They are hopeless and defeated, and they believe that treatment won’t work. Nothing could be further from the truth. Addiction is a disease of the brain, a disordered brain. Once a person is in the throes of an addiction, free will is not operating anymore. As with any disease, people who have been ill for a long time, people who grew up in families rife with addiction, need more intense treatment over a longer period. It’s not easy to find that. It may be expensive.

I listened to an interesting webinar today, presented by the American Society of Addiction Medicine on what the Surgeon General’s Report, Facing Addiction in America, means to clinicians treating addiction. Dr. Thomas McLellan of the Treatment Research Institute was one of the speakers.  He points out that 94% of addictions start between the ages of 12 and 25. So that means that we probably aren’t starting treatment early enough.  Addiction related deaths account for 74% of deaths in the 12-25-year-old age group.

Physicians have a role in this abysmal statistic as well. I can say that because I am one. We have been too quick to prescribe opiates and not good enough at monitoring our patient’s use of them. I think, however, that we are getting a little better at understanding when and how to use opiates, when to not use them, and alternative treatments for pain.  However, what I still find infuriating is the negative attitude that many physicians have towards patients with addiction, even patients who are in medication-assisted treatment. I thought we learned better in medical school. You don’t let your personal biases interfere with your treatment of the patient. I’m afraid we’ve lost that concept in the medical profession.

Unfortunately, addiction is like cancer. If treated early and aggressively, the patient can be saved. But if treated too late, some people won’t make it.  I would be willing to bet that someone in your inner circle is struggling with addiction. Open your eyes. Get them into treatment if possible.

And remember, if people don’t have health insurance, they don’t have access to treatment.

You can read the Surgeon General’s report at addiction.surgeongeneral.gov.