Saturday, May 14, 2011

Dear Mr. President

Dear Mr. President,

I know that over there in Washington you are surrounded by countless health care experts, gurus, academic and nonpracticing physicians. I know that you have had your fill of opinions from almost everybody...but I was hoping to add in just one more. You know...the opinion of the lowly primary care doctor in a small private practice. The kind of doctor that at one time made up a majority of the physicians in the United States. I know I am still quite young...but maybe I have became the dinosaur. Either kind will be extinct soon.

We hear from the media and the government all the countless benefits of health care reform. I thought you might want to know what is actually happening on the ground. To those working in the trenches and providing the actual health care.

Profound changes are afoot. You have revolutionized health care. And I hear you. I know you want to beef up primary care. How important you have told us it is. I even enjoyed my frst 10 percent bonus check recently. Well actually 8 percent (after you cut out co pays, and secondaries, etc). Well actually more like 5 percent if you include medicare hospital work for which we don't receive the bonus.

But I think you ought to a practicing primary care job is actually getting harder since the changes. Less enjoyable. More full of paperwork. Maybe I can provide a few examples.

Medicare came up with the brilliant idea to cut down on home health fraud by making sure that each patient needs a documented face to face visit and a physician to sign off before home health is provided. This is great. Save money. But did you ever think about who would have to fill out all these forms?

Yes each form only takes about 1-2 minutes. Doesn't sound like much. But when you do this day to day over thousands of patients it gets tiring. Just added work. It's great that you want to cut down on fraud. But why do I have to be your police force? Why do I have to use uncompensated time to do your dirty work? You know the specialists won't fill these forms out...they turf it to the good old primary care doc. I know what your saying now....well you get to bill for the visit. But I was seeing those patent's anyway. If they were sick enough to need home health likely I had seen them in the office/hospital/nursing home in the last few days already. More paperwork. More time. More hassles.

And lets hear it for EMR's. Your incentives to get them up and running is great. In fact over the last few years we have payed over 100k to have ours implemented. Recently my company misys/allscripts has written us that for only 15k more we can be prepared for meaningful use. should be easy if I get that incentive payment from the government to pay for that investment. Never mind that I already spent 100k in the first place. Never mind that if this is anything like the pqri program only 50 percent who try for it will actually get payed (and then what a colossal waste of money if I don't make it). Never mind that to read through the meaningful use criteria and fully understand it will either take a large investment of time (hundreds of pages of minutia) or an expensive consultant to actually use the system meaningfully.

Speaking of EMR's my hospital has been on the forefront of implementation. I have been using Epic for years. The quality Guru's now tell us that med reconciliation is by far worth the bang for the buck. So our hospital has now implemented a new med reconciliation tool. This will help the hospital track such important quality indicators such as "aspirin use at discharge for cad patients", "or smoking cessation counseling". This is wonderful. In concept. In reality now I have to fill out three forms as opposed to one when I discharge a patient. Med reconciliation adds 5-10 minutes to my discharge process. No problem...unless you are trying to discharge 3-4 patients at once. I have even seen less scrupulous physicians...especially when covering for a partner...keep a patient an extra day just so they wouldn't get stuck with the laborious discharge paperwork.

And by the way...the specialists are getting incredibly good at handing off the extra work. I got a call yesterday from one o the floor nurses. Dr. X says that his uncomplicated elective post op hip replacement is OK to leave the hospital and go to the SNF. "He is asking that you do the med reconciliation, discharge instructions, and COC form...his PA says they are not qualified to do this paperwork."

Then don't forget the new rules on narcotic prescriptions and hand written scripts....boy this has made taking care of nursing home patients fun!

I could continue with more examples.

In the near future I will likely have my rates from medicare cut significantly for eperscribe, pqri, meaningful use...the list go on and on. Some of these initiatives I will be able to comply with. Others I won't. My bet is that even if I try I will be found non compliant by medicare for one reason or another and not get my incentive bonus. Each of these incentives will cost money and precious time to implement. Time taken away from patient care. What medicare giveth (a 10 percent bonus in primary care) it will find another means to taketh away (pqri, eperscribe, meaningful use).

I think I speak for a large portion of primary care physicians in saying that what we see coming from ACA and the government scares the heck out of us. Already our work loads are increasing. Already we are being pushed to do even less hands on patient care and even more laborious paperwork.

I became a physician to help people...not to do paperwork...not to do community health....not to become the read headed step child of medicine. Just me and the patient. My ears, my hands, my pen.

Most of the people excited about health care reform are the ones who don't actually practice it day to day. Administrators, politicians, academicians, consultants, medical students, public health experts. They don't have to walk a milke in my shoes.

When medical students ask me about my choice of speciality I is the most rewarding field...but I certainly would have never chosen it knowing what I know today.

When my children ask...I exhort them not to become a physician.

I hope this opinion finds you well and adds to the plethora of voices whispering in your ears.

Sincerely....and with profound regret

A dinosaur soon to become extinct


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