Doctor burnout, high costs mar health system
There has been quite a buzz about the movie “Escape Fire: The Fight to Rescue American Healthcare.” So I was pleased to see it showing at the Virginia Association of Free Clinics annual meeting I attended recently.
But I cringed at the scenes of one doctor telling how burned out she was from the crazily busy, conventional practice of fee-for-service medicine.
The movie’s slightly strange title refers to the trick used in fighting forest fires, where you burn off combustible material around you to make a safe zone. Presumably the producers think this is an analogy for American health care.
“We spend twice as much as any other developed country on health care per person, but we’re 50th in life span,” noted co-director, Matthew Heineman, in an interview on the Documentary Channel website.
He was making the point that our system is not providing good care, and it’s also bad for providers.
It is well known that primary care medicine is a high-productivity business. And the usual reaction to more demand, and falling profit margins, is to crank up the machine and churn more patients through the office—which tends to be bad for everyone.
“Escape Fire” points out many of the foibles of our health care system: over-reliance on pharmaceuticals; the public’s poor health habits; lack of preventive care; and relatively poor pay for primary care doctors.
But one point they emphasize is how broken our system of paying for care is. The movie shows anguished scenes of primary care Dr. Erin Martin, tearful and frustrated with the madness of seeing too many patients whose problems she can only scratch the surface of.
The movie then shows her in a holistic practice she moved on to. Here she is ebullient. She can take as long as she wants with the patients and really drill down to the causes of their diseases and practice true prevention.
At the Moss Clinic where I work, we’re dealing with the same question many other practices are: How do we provide good care to an ever-growing population?
Although everyone is working hard, I can see no other solution than to “crank up the machine.” It’s a policy I have been reluctantly advocating.
So, as Erin Martin cried in the movie, I cringed. I could feel the other Moss Clinic staff taking this whole message onboard—and feeling that that we were going in the wrong direction.
WHY NOT CHANGE?
In the movie, Dr. Dean Ornish describes a variety of alternatives that can prevent illnesses and get to the real cause of diseases. He tells us you can turn back the clock and reverse heart disease by change of diet and exercise. You don’t need drugs and coronary artery bypass.
So why don’t we implement these common sense, “macrobiotic” type solutions? Why don’t we put more effort and emphasis on getting patients to eat right and exercise?
That would be better for the patient, better for the doctor, and likely a lot cheaper than providing a mass of expensive tests and treatments to people once people get sick.
But making radical changes in medical care tends to be slow and difficult. And there’s a lot of money to be made under the current model.
Still, our current system’s unsustainability and drag on the economy has people looking at new models. “Accountable care” and “bundling” are the new buzz words.
In this new way of paying, the doctor gets paid a fee for providing overall care—and gets the same amount whether the care is straightforward and cheap or complicated and requiring expensive extra care.
This provides very different incentives then getting paid a fee for service, where you make more if something goes wrong and you have to provide more treatment.
A trailblazing medical group, Care More in southern California, is one of these accountable care organizations that gets paid by “bundling.”
Their progress is reported on in a feature on new health care models on the University of Southern California website.
With this model, great emphasis is placed on preventing expensive complications—which, though it can save a lot of money, isn’t exactly rocket science.
The USC report describes how Care More puts great effort into good coordination and communication. They make sure, for example, that patients understand the discharge instructions they are given when sent home from the hospital—as failure to follow these instructions often leads to the patient relapsing and having to be readmitted.
This strategy seems to work, as their hospital readmission rate is 10 percent versus the 19.6 percent rate in the Medicare fee-for-service model. Care More also provides assiduous wound care, notes the report, leading to a much lower rate of amputations for diabetics with foot ulcers.
And they do house calls on apparently noncompliant patients. The report tells of a “low-tech” fix for a situation headed for a likely expensive disaster. The situation: A “noncompliant” arthritic lady who was wasn’t taking her pills—because her hands were so bad she couldn’t open the bottle.
Care More is ahead of the game in the brave new world of Accountable Care Organizations. And its model is something we should all be paying attention to as it is a win-win-win—for the patient, the doctor and the economy.
By comparison, the current fee-for-service model rewards “doctors or institutions for not taking care of patients well,” claims Care More’s Chief Medical Officer, Dr. Ken Kim, speaking in a panel discussion before the 2012 National Health Journalism Fellows.
It seems cynical to think that it has to be money that motivates common-sense changes in medical care. But am I being naive?
At the Moss Clinic, there are no charges for treatment, so payment method is not a factor. But still, finding some way to restructure and provide holistic, in-depth care, instead of “cranking up the machine,” might be a good thing. At least, that’s what I felt everyone was thinking in the dark of the auditorium.
Dr. Patrick Neustatter, a longtime family practitioner, is the medical director of the Lloyd F. Moss Free Clinic. He can be reached at firstname.lastname@example.org.