BureaucracyWhether one agrees or disagrees with Obamacare in the United States, the amount of paperwork for primary care doctors is diminishing their ability to deliver the best care. The Affordable Health Care Act (a dizzying patchquilt, of regulations that was fashioned by those who never spent time “in the trenches” as primary care providers except in academics ) adds yet more paper burden to the practice of medicine and when coupled with the demands of insurers (each insurer has different forms, etc.) offices are being crushed by the volume of work that has NOT been demonstrated to make one iota of difference in patient care and outcome. Added to this is the ever increasing demand by patients for FMLA (forms) which leads to short term disability forms (more forms and each one coming from a different insurer and requiring different information) which in many cases leads to long term disability requests (even more and varied forms). As if not enough, office staff must deal with referrals, billing, collections, refilling of bills to insurance companies denying payment for various reasons, scheduling of appointments to specialists, refilling prescriptions, paying bills and answering routine patient questions. Specialists demand referral approval before they will see patients- even if they are not required to have it just to cover their backsides if a billing issue occurs so they can point to the lowly primary care provider- “it was his/her fault”- more work yet for the frazzled primary care doctor and staff.

I am not advocating one form of care or another but, in a study published in Health Affairs ( a prestigious health care publication) physician practices in the United States spend four times as much money as do those in Ontario, Canada, to cope with paperwork and communications involving health insurers and payers, according to a study published Aug. 4, 2011. In many practices, overhead has soared to nearly 80% of revenues. Do not fool yourselves into thinking that free market forces will cut the cost of care. That is an uninformed pipe dream. Insurers (private business) is just as responsible as the Feds for adding to the unbelievable burden of bureaucracy that we face in health care in general and in primary care specifically. One of the main reasons that you are seeing nurse practitioners take over primary care is because there are not enough primary care doctors and I cannot imagine why an intelligent and committed physician after so many years of training would even consider becoming a primary care doctor. I am sooo happy that my kids are not going into medicine! Now, to be sure, most primary care doctors are employed by large groups. The groups supposedly will be able to manage the volume of paper work. (I doubt it.) Theoretically, they will manage the bureaucracy better because of economies of scale. (I have heard that fantasy before as well.) The “new” docs are salaried and so they are less worried about paying the rent. In theory system staff will fill out the never ending sea of forms. BUT, they are more removed from you as well. They have a job- 9 to 5. They are not answering directly to you as one might in private practice. They get their paychecks from large groups, insurers or hospital institutions and this means NUMEROUS conflicts of interest with regard to what is best for you. If you are employed by hospital system X and the patient requires a surgery better done in hospital system Y where are you sending the patient? X of course! (It may not be better for you, but it is best for the system!) By the way, like in any job, doctors transfer, get fired and businesses fail. That is just starting to happen in the world or corporate health care encouraged by Obamacare.

In a job- just like in your job- doctors will do their best, but, their personal engagement with their “custome”r is limited. There once was a time when your doctor called you back when you had a query or when you called at night your doctor responded. Now, a nurse screener (someone from a contracted service and who does not know anything about you) will call you back- NOT the doctor. OR, you may not get a call back from your doctor for days or weeks! Hey, it’s a job!!!!!!!!  

OK, there are still a number of private docs, but, to survive decreased reimbursement and increased overhead, they chug-a- lug patients (in and out of rooms) to hold the line on revenue, and they cannot call back because like me they are slammed with paper work. (By the way, Mr. Obama and his health team talk of computerization, electronic medical records, sharing of data, blah, blah. In reality, the change will take a decade at the very least. Meanwhile, in health care we still kill off forests for the paper we use for no reason at all.) What will I read or answer today? The ton of paper I have on my desk or the reams of electronic records I need to go through for patient care? Will I have the time today to even get to the old records of Mr. James – hundreds of pages- which might give me important information about his care? My staff has to convert his paper records to PDF in my system (Electronic Medical Record or EMR) and I will read them – unformatted- if there is time (not!). Oh yes, the EMR’s that have been foisted on docs do not necessarily decrease the time in patient care so as to make record keeping more efficient. Instead, it promotes “checklist” medicine. EMR’s may not actually make care more efficient or really improve quality. BUT, it will LOOK good! The companies that are making a fortune selling medical software and hardware at insane premiums – even insurance companies are selling systems – and the feds will NEVER say they failed or this was too much, too soon. They will spin it to sound like a resounding success! Meanwhile, guys like me- your docs- are being buried. Primary care as you would want it will not rise from the dead.

There are some days when I wonder what the hell am I doing? After seeing patients, I fall into my chair and stare at the pile of forms and records that I must read or fill out or respond to. I got up at 6 AM and I will just burn out by 8 PM at night and I am DONE!!!!!!!! On the way home, I hear some talk show analyst saying that doctors need to “become more efficient”. I am thinking about rent, payroll, medical supplies bills and medical malpractice bills coming up and oh, by the way- I have a family!