Up until the 1960’s the doctor-patient relationship was an important component of the healing process. The patient relied on his doctor to do the “right” thing and the physician did whatever he could to help his patient get well. Many patients had no insurance and they would pay the physician what they could. Some of the payments were “in kind” and the physicians were generally satisfied with this. Most cities had one or more “charity” hospitals which took on care of most of the indigent patients. Cook County in Chicago, Bellevue in New York, and Charity in New Orleans come to mind.
The relationship was to change dramatically in the 1960’s when Medicare came into being as part of President Johnson’s “Great Society”. Patients over 65 would have the government pay for their health care and the payments were structured on a “fee for service” model. The more things that the physician would do to the patient, the more he could charge under Medicare.
Medicaid came into effect in 1965. This program offered federal funding to the states to help pregnant women, children, needy families, the blind, the elderly, and the disabled, to get medical care when needed. There were federal criteria that the states had to meet in order to get the funding and by 1982, every state was participating in this program. In fact, federal support of Medicaid is now more than 10% of each state’s total revenue.
Under the Affordable Care Act (ACA), Medicaid was expanded to cover more patients. For states to opt in for the new Medicaid, they would have to provide coverage for all adults with incomes up to 133% of the federal poverty level. This was a huge expansion of Medicaid and a large part of the costs would be paid by the states. Many states chose to opt out of this expansion and the Supreme Court ruled that these states would be allowed to keep Medicaid the way it was before the new requirements under the ACA (see National Federation of Independent Business v. Sebelius).
Third party payers were quick to follow these federal models and before long, health care costs started to rise dramatically. It was not surprising that more tests would be ordered and more procedures done on patients in order to increase remuneration; both for physicians and hospitals. Subspecialization became more common as incomes could rise with the procedures associated with subspecialties.
The physicians were not the only ones to blame for rising costs. When the government starting paying the bills under Medicare, many patients started pushing for more tests and treatments even if there was no clinical indication to do so. People started to believe that they were entitled to all of the expensive tests and procedures; the physician’s judgment was often overridden by patient desires. Many patients were calling the shots. This problem became exponentially worse when the internet made information easily accessible to everyone; many laypeople came to believe that they knew more than their doctors and they started to dictate their own care.
Thoracic surgeons who would do both cardiac and general thoracic surgery along with some general surgery cases found that they could make a lot more money if they would concentrate on the relatively new specialty of cardiac surgery. Coronary revascularization became one of the most common operations and the cardiac surgeons would spend their day in the operating room doing coronary artery bypass grafting (cabg) all day long. Other patient care was relegated to non-surgeons as the non-operative care was not nearly as lucrative or interesting. It was not uncommon for the cardiac surgeon to have no more than a superficial relationship with the patient and his family as that would take time away from performing open heart operations. The non-operative doctor- patient interactions were just not cost effective.
With the government and other third party payers paying for most of the costs, it was foreseeable that new regulations and clinical oversight would come into play in an effort to get control of the ever increasing costs. Regulations came from several sources; hospitals, licensing boards, state and federal government, Centers for Medicare and Medicaid Services (CMS), the American Counsel for Graduate Medical Education (ACGME), American Counsel for Continuing Medical Education (ACCME), the Joint Commission for Accreditation of Hospitals, the American Board of Medical Specialties, the Food and Drug Administration, and others.
Laws emanating from the Health Information Portability and Accountability Act (HIPAA), the Affordable Care Act, anti-kickback statutes, the Emergency Medical Treatment and Active Labor Act (EMTALA), the False Claims Act and others, added to the complexity of medical practice and forced the health care providers to purchase expensive items such as electronic health records (EHR) systems, medical records specialists who had knowledge of coding requirements, and consultants to make sure the practice was in compliance with the laws.
With the laws and regulations that had to be met in order to get paid, more hours were spent on administrative duties and away from actual patient contact. For those of us who became physicians in order to help people, the administrative work seems to get more onerous every year and there is no relief in sight.
Taking care of patients is an enormous responsibility and it can be physically and emotionally draining. If I am up all night fixing an aortic dissection—not a rare occurrence, it takes me days to recover. The demands of the clinical practice, the ever increasing administrative responsibilties, the fear of being sued for medical malpractice, and the penalties that can result from violating one of the medical laws we are responsible for following can be wearing.
A recent study published in the Annals of Internal Medicine in September 2016 reveals that one-half of a physician’s work day is now spent on administrative work including EHR entry. Only 27% of the day was spent on actual clinical time with patients. With much of this administrative time spent on fighting with the payers who are intent on denying payments and pushing for less costly, but not clinically indicated care, it is no surprise that physician burnout is at record levels.
So what is “burnout”? According to the American Academy of Family Physicians, it is a syndrome characterized by “a loss of enthusiasm for work (emotional exhaustion), feeling of cynicism (depersonalization) and a low sense of personal accomplishment.” This can lead to an increased rate of medical errors and a lower rate of patient compliance for chronic disease management plans. If the physician seems uninterested, the patient is less likely to be as interested himself.
Speaking of burnout, a recent study by the Physicians Foundation (Merritt Hawkins 2016) showed that 49% of physicians met criteria for burnout. In some specialties, the burnout rate was up to 60%. This cannot be good for patients seeking care. Medical care is very complex; much more complex than when Medicare came into being. No patient would want to be cared for by a burned out physician when the importance of the clinical decision can be life saving; or threatening.
Between the financial burdens and the complex laws, the future for physicians, and other health care providers is no longer as satisfying as it used to be. I have had a stellar career and I still enjoy what I am doing but, as the burdens increase, retirement is looking better every day.
Dr. Weiman’s website is www.medicalmalpracticeandthelaw.com
Dr. Weiman is the author of Medical Malpractice and Fundamental Issues In Health Care Law