By Linda D. Bosserman, MD, FACP
Medical Oncologist, Wilshire Oncology Medical Group, Inc.
Board Member, San Bernardino-Riverside County CMA
Results from the recently released survey of over 2000 of the estimated 60,000 practicing physicians in California should get the immediate attention of patients, insurers and legislators. Without significant changes, physicians are telling us that we can expect further decreases in the availability of quality medical care in California. Physicians in all counties and all specialties expressed their dissatisfaction with the practice of medicine, primarily because of the decreased relationships and time spent with their patients. This has been brought about by the increasing demands of managed care, increasing government regulation and loss of autonomy at a time when reimbursements have been drastically reduced as California insurance premiums have been allowed to fall 40% behind the national average. The physician message is clear: 77% in San Bernardino County and 88% in Riverside county are less satisfied with the practice of medicine. Doctors are planning action with 55% of San Bernardino County physician responders and 42% of Riverside County physician responders planning to retire early, move out of state or change professions in the next three years. What is behind these physician messages?
Give Us Back Our Patients!
The physician survey points out that the greatest source of satisfaction for
physicians is that which patients say they want most: a relationship. There
are no more comforting words when you are vulnerable and ill that a physician
saying, "I will take care of you. I will be your doctor." Yet managed
care has made it clear to physicians that the patients are not their patients
but rather patients of the managed care system to be treated in whatever way
maximizes the health plan's profits. This behind the scenes change has eroded
the patient-physician relationship and reduced physicians to checking off boxes
of approved, generalized treatment plans sanctioned by under funded managed
care groups rather than working with their patients to find the best possible
medical care for their individual disease or illness.
Doctors are expressing their increasing inability to have their voices heard
and are leaving or changing careers because they cannot daily face their patients,
knowing they cannot do their best for each patient that they see. This medical
ethic is so engrained in doctors at every level of medical training that it
is second nature. No one would work the hours, the call or with the intensity
of physicians for financial gain alone. The real satisfaction is in knowing
you brought your years of training, personal sacrifice and experience to the
bedside to benefit your individual patients. The reward is to see the major
impact on healing, coping, survival and quality of life that we work with our
patients and their families to achieve throughout their lives.
Stop Devaluing Us as Individuals!
As patients are forced to change medical groups, as frequently as yearly, doctors
feel that their many hours of personal sacrifice, expertise and personal service
are not valued by patients. Patients have not been successful in maintaining
their doctors when employers change health plans to minimize health care payments.
Patients often can't fight to get to or keep the best doctors because they are
only offered one health plan through their employer and individual health insurance
is prohibitively expensive.
Patients are reassured by health plan salespeople that the doctors in the new
group will meet all their needs and are encouraged to pick new primary care
physicians and specialists, reinforcing the health plan's ideas that all doctors
are about the same and a longstanding personal relationship is not an important
component of good medical care. Doctors are left with the message that their
individual efforts are not important which makes retiring, moving or changing
careers that much easier. Doctors in the past often worked inhuman schedules
and retired late in life as they felt such a lasting commitment to their patients.
As the relationship between physicians and individual patients has been devalued,
physicians are reacting in ways that patients don't like. Patients who call
with emergency medical needs are sent to urgent care or emergency facilities,
as doctors are already booked maximally. When patients were felt to be the responsibility
of the doctor, offices worked through lunches, breaks and after hours to take
care of their patients. Now, doctors schedules are so overloaded to meet increasing
overhead costs that they are forced to send their patients to unknown doctors
at urgent care centers or emergency rooms for same day medical emergencies like
urinary track infections, acute bronchitis, sprains, fractures, lacerations
and other health care needs previously treated through planned openings in their
regular office schedule.
Value Our and Our Patient's Time!
Neither the doctors, their staffs nor their patients' time is valued. Patients
are sent all over the area for lab work, X-rays and procedures where they frequently
wait hours at a time for each needed examination. Managed care's message is
clear: their ability to save a few pennies on each exam is more important than
the patient's time and comfort. Doctors are spending more of their and their
staff's time chasing down results of exams and tests after waiting on hold for
increasing amounts of time for authorizations for all manner of testing. Rotating
staffs of laboratories, pathology labs and radiology facilities lead to less
reliable test results and frequent calls from physicians to clarify results
or get comparisons to previous X-rays done at other facilities. Staff and doctors'
time is being tied up for work that is useless in improving outcomes for their
patients and that does not use their years of training and expertise to accomplish.
Filling out forms for procedure requests, consult requests, disability, medical
necessity, pharmacy prescription rationalizations, phone calls from medical
and pharmacy directors, managed care meetings all take time away from patients
and are uncompensated for yet the survey shows doctors spending 5% more of their
time in these activities over the past 5 years.
Our patients are increasingly angry at the time they waste waiting for tests,
exams and doctors and the many visits where needed results are not yet available
to review with their physicians when they finally get an appointment. Patients
complain their doctors don't have enough time to spend answering their questions,
developing a plan tailored to their individual needs or meeting their emotional
needs during medical crisis. Patients' increasing anger makes it even more difficult
to build trusting relationships. This decreases compliance, increases physician
stress and increases medical costs.
The marked increase in workload without increased funds to meet managed care
and government mandates has further left the health care system overstressed
so that there is no reserve among health care professionals from techs to secretaries,
nurses and physicians to compassionately meet the needs of sick patients who
are often frustrated, uncomfortable, scared and impatient. By undervaluing physician,
nurse, secretary and technical time through managed care underpayment we are
producing short tempered, frustrated, uncaring medical personnel who are getting
the message that they are just cogs in a wheel, easily replaced and voiceless
to change the system.
Nurses have already left the field in significant numbers and are not being
replaced. This is resulting in the closing of hospital beds throughout our communities
and is jeopardizing hospital care. Nursing positions are increasingly being
filled with expensive, less trained registry nurses with no long-term commitment
to our community's health. This has increased physician stress as patients receive
poorer care and patients and families complaints are increasing. The current
CMA survey shows a similar situation developing with physicians across California
in all primary care and specialty fields who report increasing difficulty recruiting
new physicians. The slowing of professionals entering practice in California
and the mass retirement, slowdown and career changes planned in the next three
years will mean less access for Californians to physicians able to focus on
providing the best care for the medical needs of our aging and continuously
growing population.
The System Shouldn't Punish Excellence:
Another major problem that underlies such profound physician dissatisfaction
is routed in California's IPA model of managed care which pits the under funded
IPA's financial success against the patient's need for care. Insurers in California
were allowed to enter a premium war that resulted in premiums being 40% less
than the national average. After doing this, however, the insurance companies
were not held accountable for the results of delivering 40% less care and numerous
IPA bankruptcies. Insurers promised Californians to insure their health while
knowingly under funding IPA's and knowing that each IPA, in order to stay in
business would have to underpay or under authorize health care for their members.
For IPA's to be successful they needed to sign up doctors who don't attract
the sickest patients, as they do not receive additional funding from insurers
for increased patient costs. IPA's that have exceptional cancer specialists,
cardiac surgeons, cardiologists and others find savvy HMO patients switching
primary care doctors to receive expensive long term specialty care which undermines
the financial viability of the IPA. Doctors are chastised for attracting sick
patients to their IPA, for knowing too much, for advocating for specialized
tertiary care and for their sick patients living longer!
The results have been devastating for physicians and patients. For physicians
three choices have emerged. Physicians can either do the right thing for their
patients for inadequate payments while risking managed care backlash and even
non payment when IPA's increasingly file bankruptcy, or, physicians can look
the other way and limit work ups so that fewer problems are identified that
require evaluations and treatments, or, physicians can stop seeing managed care
patients. The survey shows that more and more of our colleagues are following
the third course with early retirement, career change or moving out of state.
Summary:
The CMA survey, with all the caveats on sample size and possible biases, should
be an awakening for patients, insurers and our legislature to implement changes
that would restore physician payments, respect, authority and autonomy before
we completely destroy a system that made state of the art medical care the previous
standard in California. The first step would be to entirely revamp the IPA structure
that has placed silent and unaccountable middlemen between doctors and their
patients. These middlemen have taken 8-15% of the health care dollar while destroying
the fabric of medical care in California. Doctors should be paid for the work
they do and the patients they see. Doctors don't take risk: doctors treat the
patients who come to them and place their trust for their lives and their health
in their hands. Insurance companies take risk. When the insurance companies
are forced to assume the risk of health care coverage, they will be forced to
be honest with those who purchase their services and make plain any limits in
coverage being purchased for limited premium dollars. Insurers once again need
to become insurers. IPA's who have served to do the insurance company's dirty
work of limiting care behind the scenes without public oversight or scrutiny
must be eliminated. Until this occurs, patients cannot trust their doctor's
advice and there cannot be the type of honest, trusting relationships between
patients and their physicians that are required to ensure the best health care
for Californians and a reversal of the California physician brain drain.
