Tales of a Family Doctor

A family doctor sat down at his computer and wrote about what he does when he goes to his clinic. The end result is an extraordinary look inside a clinic focused on family practice and the stresses that the current health insurance system places on the people in such an establishment.

I arrived this morning in the office at 8:50 a.m. to find Glenda, my office manager, buried in charts. She had been there since 6:30, simultaneously arranging referrals that had been requested the day before, making sure that we had properly completed the detailed forms required by the Child Health and Disability Prevention Program that helps pay for the preventive care provided to some of our poorer patients, and listening to the voice mail from pharmacies to get the medication refill requests in order for me before the day begins in earnest.

Glenda is a great asset to the practice. An extraordinarily hardworking mother of two, four days a week she commutes with her husband from an outlying suburb to the office, arriving early to avoid the rush hour gridlock and get some of her work done before the phones start ringing. Having been with me for about ten years, she knows the ins and outs of dealing with all the health plans-- which ones require paper referrals, which use the Internet, which force her to hang on the phone waiting for an okay. Only Medicare is easy; all we have to do is provide a patient with the name and phone number of the consultant. MediCal, the California Medicaid program for certain categories of poor people, works the same way in our county but it is a bit more complicated. Not all the consultants we regularly use accept MediCal referrals so the list of available consultants is limited. Glenda is playing what I think of as a game of "keep away" we play in our office. The providers, knowing medicine but not the details of each health plan, send administrative work to the staff; Glenda and the rest put their stamp on the process and return the charts back to the doctors. Eventually the game pauses, but right now Glenda is "losing" with over fifty charts on her desk.

My office, a small practice which I own and staff, has grown over the nearly 20 years I've been practicing family medicine in the San Francisco suburb of Burlingame. At first I worked alone, delivering babies, assisting at surgery, rounding on my hospitalized patients, but always spending most of my time seeing patients in my office across the street from the hospitalOver time, in order to make sure that I could take vacation and to spread the overhead, the practice has grown and now we are a group of five part time physicians and two nurse practitioners supported by seven full and part time staff. [...]

Shortly after I arrive and begin to call back patients who've left messages overnight Glenda comes by with a small stack of charts that have been giving her trouble. A couple require a short letter from me changing the "diagnosis code" I used when completing a lab order form. Some insurance companies, it turns out, do not pay for preventive screening tests, so when I ordered a cholesterol or a prostate cancer screening test at the time of a physical, the test would not be covered under a patient's insurance policy. Fortunately, the lab often catches these slips and notifies us so I can correct the "error". For better or worse, the two patients' whose charts she brings today have elevated cholesterol levels, so I feel honest indicating that fact in the letter, knowing that the insurance company will not balk at payment. [...]

The private health care insurance system which we deal with every day is an insidious bureaucratic monster. The morass of more than 1300 insurance carriers in this country introduces an administrative mess beyond belief. In our small office of essentially two full time equivalent providers, seven full time support staff are needed to cope with the complexities introduced by this system. I am quite certain that the wasted effort this system creates is so great that if we had a unified system of health care I could see 10-20% more patients - with two fewer staff. Looked at from another direction, at least 10-20% of my current income is wasted on insurance bureaucracy which benefits no one. [...]

Three medical assistants spend hours daily communicating with patients about medication refills and calling or faxing pharmacies. Most insurance companies allow patients to collect only a one month supply of medication at their local pharmacies (three months if patients can figure out how to manage a mail order program). The rule makes financial sense for insurance companies. Why should one company pay for a year's supply of medication if a patient may well switch insurance companies or lose their coverage after one month? Unfortunately, the rule doesn't make sense for patients. Studies show that compliance with chronic medications is abysmally low, in part because of rules like this.

The churn in insurance coverage as people move, change jobs, or suffer economic hardships which lead them to cut back on expenses introduces a huge set of problems for our little office, and wasteful costs for the medical system. Easily half of the new patients we see explain their search for a new doctor (no small task in a community where primary care providers are retiring in far greater numbers than they are starting out) as the result of an insurance change. So we often "reinvent the wheel", setting up a new chart, getting to know a patient, revising medications, reviewing old medical records, helping those with complex medical issues reestablish with new consultants. The economic implications for the system are obvious.

There's so much more in his post that I encourage you to go read the original. He concludes with some thoughts about the future of health care in America and he makes a lot of sense. Let's hope people who need to hear his input are listening.

The doctor's name is Aaron Roland and his bio notes that he "is a family physician who years ago left Yale Law School and a career in politics for the front lines of primary care. He now returns to fight for national health insurance for all." His opening comment mentions the organization, "Physicians for a National Health Plan" or PNHP, specifically pointing out a blog at the PNHP website which may be of interest.