I already know I sound like a broken record. Yet I can’t fathom why I seem to be the only person talking about this. There have been numerous articles in both syndicated journals and in the blogoshpere world about the many things wrong with the American Healthcare system, including the overspecialization which we know leads to higher costs (but not necessarily better outcomes). Just as I feared, the NYTimes published this Letter naively promoting Medicare for All. Now progressives all over twitter are hashtagging Medicare4All. To quote a classic, “You’re killin me smalls!”
I’ll try to explain with non-medical and medical analogies. First, let’s use the construction of a house. If the foundation has an issue like a crack due to time or wear and tear that has made the foundation weak relative to the growth of the house and the environment, you wouldn’t just keep patching things around the house and assume it’s going to fix the problems for the long-haul. You may not have the money to rebuild the foundation, but you would know all the patches you are fixing are just temporizing measures because ultimately the foundation must be strong and appropriate to sustain the weight and mechanics of the house long-term. You also know in the back of your mind that if you are only doing temporizing measures, at some point the slightest stress could bring the entire house down.
For a medical analogy, I’ll use one we Geriatricians think a lot about: the prescribing cascade. A relatively healthy 60 year old starts taking alleve (or any NSAID) regularly for her osteoarthritis. It’s over the counter, and it works. She continues her alleve for years until she sees a new PCP at age 65 and is found to be hypertensive. Lisinopril is prescribed, but it’s not enough. Hydrochlorothiazide is added. Eventually she’s placed on a PPI for reflux symptoms. She later develops a hot swollen toe and is started on allopurinol for Gout. All of these medications were started appropriately relative to the symptom, however routinely medical providers don’t stop to ask if perhaps there is something at the beginning that caused the cascade of medication pile on. NSAIDs cause reduced perfusion to kidneys, which leads to elevated blood pressure particularly with chronic use. Hypertension must be addressed. But the BP meds have side effects (like thiazides can cause gout). Likewise the NSAID causes a more acidic stomach, then a patient needs a medicine to fix that. Chronic PPI use is associated with higher infection rates. It goes on and on. But the doctor or provider who sees the whole-picture and appreciates the value of the long-haul would dig deeper before prescribing the first anti-hypertensive and question what the patient takes over the counter. In doing so, they would remove the NSAID and suggest safer pain management along with lifestyle interventions. The initial base treatment for her primary issue needs reformed, because it no longer makes sense. It’s also causing a cascade that ultimately will lead to earlier morbidity and mortality for her if the reflexive approach of only treating symptoms is continued.
Medicare uses the “Relative Value Unit” or RVU to determine what they deem is valuable from physicians and thus decide our pay. However, the formula for the RVU prioritizes procedures and high-volume patient turnover to time-based care. Essentially, Medicare does not pay doctors for their time and knowledge. Insurance companies use Medicare reimbursement rates as their standards, so even doctors who see children and young adults are essentially held to the Medicare standards. Unfortunately, this blanket approach to all of medicine from Medicare and now the entire industry neglects to recognize the vast diversity within the medical field. My husband is an Anesthesiologist. Other than our medical school years, our real training could not be more different. I could never do what he does, and he can’t do what I do. Yet, in applying the same RVU schema and formula to all types of doctors, Medicare has now steered physicians away from primarily time and knowledge-based fields, like primary care, geriatrics, and general internal medicine, and into the specialties that only have to focus on one body system and also have lots of procedures (it takes a lot more time, mental energy and documentation if you have to think about all systems interacting including the patient’s preferences than to focus on one system).
I see headlines like “Doctors: You have a PR Problem” and “The Specialists Stranglehold on Medicine.” Of course I stay up to date in all the rage of value based payment models. I keep thinking someone surely must notice that there is a primary issue that has led to this cascade of distrust in doctors, too few primary care physicians, physician burnout, poor outcomes for our patients, and high costs. Good care takes time. Trust takes time, Building knowledge takes time. Sifting through 10 medications to find true offenders takes time. Taking a thorough history and physical takes time. Solving the pieces of the complicated patient puzzle takes time. But no one has yet mentioned reconsidering how Medicare pays doctors with an inappropriate one-size-fits-all-physicians approach. And I shake my head, because I have seen this so many times. Value based payment won’t improve outcomes if the primary incentives are not aligned with value. Even if you salary me, making me stress about ICD10 codes (rather than differential diagnoses) and worrying about every code modifier and patient number during my day will still detract from my ability to focus on my patients. The value based models are like the allopurinol in my analogy relative to the health of the entire healthcare system.
Whether we move to universal coverage, or purely privatized medicine, or continue with our current ineffective hybrid system, there is one thing I can say for sure. If Medicare remains as is, none of the band aids will fix the bullet hole (thank you Taylor Swift) leaching money, quality, and physicians from US Healthcare.