PRACTICAL CONCERNS

Collective Health

By Anne French, MD

I’ve done what was once unthinkable—I closed down a 45-year-old solo family practice in the fall of 2006. My father ran the ship for 42 years. I came along to experience this rare dying breed for a mere three years, and then decided it was time for hospice.

Ever since residency, I’ve had the sense of holding my breath, waiting for the medical system to collapse entirely, so that it can rise anew and become a viable system that truly cares for the health of our nation. When I was mired in the muck of a frantic 16-hour day filled with hundreds of detailed tasks, often involving significant liability for people’s health and lives, it felt impossible to be part of the solution.

My original decision to take over my father’s practice took me by surprise. I left my salaried position at the Sonoma County Indian Health Project and was propelled headlong through a crash course in small-business ownership, practice management, and being the sole provider for not only 3,000 patients, but also five employees. I learned the reality of partial and delayed reimbursements from the insurance industry, and of productivity-based income. To avoid compromising my ideal of quality, I limited the number of patients to 18-20 per day. This limit allowed me to break even, but I was still working 80 hours a week.

It’s taken some retrospection to realize that I was running a private nonprofit. I loved the autonomy of solo private practice, I loved practicing my own blend of allopathic and integrative medicine, and I loved my patients. But I knew the pace was not viable, and that I was at high risk for burnout. I also could not tolerate any more incursions on my time or my income. I was getting paid for only 50% of my time and effort. Sure, my patients were happy, but the workload and the financial equation were not sustainable.

I currently work for the State of California, at the Sonoma Developmental Center. I’m on hiatus from private practice, with a strong desire to protest our current system. As long as I continued to contract with insurance companies, I was part of the problem, not the solution. I was allowing these companies to further exploit the medical system, by accepting their corrupt contracts and their delayed payments. Needless to say, a year and a half after closing my practice, I am still owed tens of thousands of dollars by the insurance companies, which still require labor-intensive redundant paperwork to refile and contest my unpaid claims.

Many forces complicate modern-day medicine. We’re very good at handling trauma and end-stage disease. We’re fantastic at bringing patients back from the brink of death. We are not so good at caring for the relatively healthy general population, with or without chronic medical problems. We’re not quite sure what to do with those patients who haven’t yet reached the actual diagnosis they may be headed towards. We look dumbfounded when patients come to us with vague constellations of symptoms that don’t fit our well-defined algorithms. We no longer know how to use tools outside of surgery and pharmaceuticals. We’ve lost our connection with traditional healing practices, ancient wisdom and common sense.

In our current “system,” it is difficult to take the time to unravel the medical puzzles that patients present with—every 15 minutes, ready or not—or to communicate adequately with patients who are struggling with illness. It is far easier to reach for the prescription pad and recommend a temporary fix that may address the symptom but not the problem.

Teaching patients all the complexities involved in preventing illness or managing chronic illness takes time. It takes time to explain why I’m not giving them antibiotics for their cold, or to teach them how to do nasal rinses to prevent sinus infections. Our geriatric patients take even more time. They may not see or hear well; they often process thoughts more slowly; and they may be taking more than 10 medications. Rushing these patients through in less than 15 minutes is not only inhumane, but also causes further problems when they misunderstand our hurried explanations. The insurance companies don’t want to pay doctors to educate patients. The pharmaceutical industry doesn’t want you to make their products less necessary.

I do believe that the mainstay of excellent medical care is prevention. Participation by the individual is critical, such as maintaining a healthy diet, exercising and not smoking. However, public health measures are also necessary. Fundamental to this goal is access to healthy food. Ubiquitous and unhealthy fast food is still cheaper than healthy food. Until this equation is rebalanced, don’t expect our financially strapped patients to turn back the obesity/diabetes epidemic.

We must commit to long-term health benefits over short-term expenses, which will require a shift in both government and public consciousness. The food equation echoes, and is interwoven with, the environmental crisis, in both severity and urgency. Countries with universal health care funded by the government have a better system of accountability towards the environment and health care alike. The governments in these countries have a vested interest in reducing health care costs because they’re paying the bill. Unfortunately, we’ve been encouraging and even subsidizing companies that don’t benefit our health or environment, at a high cost to our people and their health, all in the name of capitalism.

The total amount of money going into our health care system is phenomenal, more than any other country in the world. In a typical insurance company, administrative costs range from 20% to 30%. These rates compare unfavorably with Medicare and Kaiser, whose administrative costs are less than 10%. The multiple layers of separation between patient and physician are not benefiting anyone except the insurance industry, which continues to rake in huge profits. Meanwhile, physicians and hospitals struggle to survive, and patients receive mediocre and substandard care for an ever-increasing price tag.

Insurance companies delay payments and earn interest on our money without any consequences. Physicians have no rights (or time to fight for them) in this very unbalanced relationship. The time has come to police the insurance and pharmaceutical industries, and to hold them accountable for their role in inflating health care costs and for their unethical business practices.

We have been discussing universal health care in the United States since the early 1900s. The discussion has been heated since the beginning, with opposition coming from surprising places, including the AMA. Today, the dominant opposition comes from the insurance industry, which has a lot to lose if we adopt universal coverage. The language surrounding universal health care has been demonized, and the populace cringes to consider “socialized medicine,” which conjures up rationing and perceived substandard care.

Reality check! We already have a form of universal health care in this country: Medicare. For the patient, Medicare covers 80% of basic health care. It is a fairly well-run program (except for the recent Part D fiasco) that could be modified to cover all patients. Can you imagine the amount of money that would be put back in the system if we used Medicare’s efficient model more broadly? With streamlined billing (only one plan to learn and use), we could cut our office staff in half. Of course, Medicare would have to be revamped to increase reimbursement rates and cover preventive exams.

Likewise, can you imagine Kaiser for all? Both Medicare and Kaiser are pre-existing models that could be expanded to cover all patients, without changing the basic infrastructure. Both Medicare and Kaiser could co-exist, offering Americans choice and competition.

Many of the common arguments against universal health care continue to be recycled in repetitive campaigns to play on our fears of long lines, less choice and substandard care. Isn’t that what we already have? We can create a viable, competitive new system that we actually want to use. We’re a creative country (although a bit constipated at the moment), and we could use some of the benefits of our capitalist society (such as competition) to create a universal health care system that fills us with pride, not fear.

The power and strength of the pharmaceutical and insurance lobbies is clearly stamped on our current medical model. The only way to revamp medicine is to have physicians and patients take back ownership of the system. In fact, if we don’t find our voices, the “solutions” will continue to be dictated by industry lobbyists and politicians. The balance of power must be restored, and a set of checks and balances needs to be applied to the drug and insurance companies, just as they are currently applied to individual physicians.

Maybe the most important thing to fight for is to keep our medical system human. When we’re struggling with illness, we all want to be taken care of with compassion, understanding and competence. Physicians bring a true sense of service and love to their work. In the current system, these values are difficult for patients to perceive and for physicians to sustain. The goal of any reform should be to create a system that retains the passion that brought physicians to this privileged work, respects and acknowledges patients, values the wisdom of basic clinical judgment, fairly reimburses physicians, and uses the best of our high-tech gadgetry to decrease health care costs.

We’ve seen many solutions proposed to this complex problem. I have hope that we, as a society, can create a system that carries out the ideals that America represents. We can start by rediscovering our voice, which is our power, in our democratic society.

E-mail: Anne.French@sonoma.dds.ca.gov