Since the advent of Obamacare, much has been written and discussed about healthcare: how it is changing and the challenges we face now and in the near future. This article is a conversation with a family physician, Dr. Bruce Blumenthal, who has worked on the frontlines for over 30 years and experienced those changes firsthand. Dr. B has seen how the changes in the delivery of direct care have affected both the lives of his patients and the way he himself practices medicine.
Q: Tell us a little about your background.
A: I attended George Washington Medical School, from 1974 to ’78 and completed a residency in Family Medicine at the University of Medicine, 1978 to ’81, the final year of which I served as co-chief resident of the department. After residency, I helped establish the Washington Village Medical Center, the first primary care medical site in an otherwise underserved area. The fact that it was considered “underserved,” despite the fact that it was only a few blocks from the University of Maryland, speaks volumes about many health delivery issues, but it also allowed me to stay in Baltimore to fulfill my public health service obligation. (We were all set to go to an Indian reservation!) After repaying my medical school loan to the government, I was hired by Timonium Medical Center, where I became its medical director and stayed for 19 years. This medical center saw a more diversely-aged population than at Washington Village, constituting more of a true family medicine practice. For the last 10 years, I have been at Oakcrest Village (a division of Erickson Living), a continuing care retirement community (CCRC) for people over 60, with a median age of 85.
Q: So you have had the opportunity to see a lot of medical care firsthand. How has the practice of medicine changed during that time?
A: Yes, as a family doc, I’ve seen all types of patients, from newborns to nonagenarians (90-year-olds) in several venues – including hospitals, walk-in medical centers, nursing homes, and hospices – and have done my share of home visits. Medicine itself hasn’t really changed, but the business of medicine has, due largely to the government’s interest in saving money and the introduction of regulations and policies. At times, this government intervention has had the unintended consequence of compromising good medical practice. After years of involvement by government in the business of medicine, medicine is now one of the most regulated industries in the country, a far cry from the vision of the doctor who worked long hours but was largely independent.
Q: How/when did all these government regulations start?
A: Beginning in the early 1970s, the Feds recognized they had a significant budgetary crisis on their hands with the burgeoning up-tick of healthcare costs. Technological advances like MRIs and CAT scans, which were rapidly becoming the new diagnostic standard, along with the aging baby boomers were putting excessive demands on entitlement programs, Medicaid and Medicare in particular. And it was only going to get worse. Something had to be done to avoid bankrupting these government programs.
My first job at the Washington Village Medical Center, which opened its doors in 1981, was essentially an experiment to see how the government could reduce Medicare expenditures on the elderly poor. The experiment entailed offering free medicine and primary care, even without a co-pay, to elderly residents. These were people, like many poor in large cities (then and today), using the ER as their means of medical care, primarily due to the lack of a health clinic in their neighborhood. Remember, this was an area considered “underserved” – even though the University of Maryland was a stone’s throw away. It was hoped that with regular checkups and monitoring of chronic ailments, as well as free medications (yet another incentive), these people would get healthier overall, require less hospitalizations, and no longer misuse the ER.
Q: Seems like a reasonable proposition. Did it work?
A: If opening up a new medical center in an otherwise underserved area defined success, then we succeeded. But this venture did not save anyone any money.
The policy makers missed an important understanding about human behavior. Yes, people will gravitate to something that is free, and that aspect did draw people to use the new medical center. However, when the Center was closed, people went back to the ER for care. Additionally, lack of even a token payment made the whole thing ripe for abuse. For some, there was over-utilization because everything, including medications, was free. We tried to run it like medical center. But with no incentive or mechanism for changing attitudes or behavior, there remained those people who treated it as a clinic – just stop in and wait to get served. (It didn’t help that the pharmacist we contracted with was indicted on drug abuse and fraud.)
A bigger issue may have been the government’s misunderstanding about the value and efficacy of preventative care. There is no real preventative care for the elderly. It’s not reasonable to think that more visits to the doctor will prevent illness and hospitalization. Preventative care, in general, only defers illness, it does not prevent it. That may sound harsh and counterintuitive, but from a purely economical standpoint, what’s called preventative care for the elderly may actually cost the government (i.e., Medicare) more in the end by keeping people alive longer.
Did our Washington Village patients take better care of themselves with easy and free access to excellent primary care? It’s hard to say. I liked many of my patients, and most truly appreciated having a medical center in the neighborhood. I’d like to think we made their lives a little bit better. But for the government, the experiment was a failure. After spending a lot of money, there was no measurable reduction in hospital or ER usage. The experiment ended, the waiver was removed, and the center became a regular medical center. And the search for a cost-saving model continued.
Q: Today, 30 years later, we are still talking about the problem of people using the ER as their means of primary care. This use – abuse – incurs $38 billion annually of wasteful spending. Are there still too few primary care options? Or is irresponsible behavior the problem here?
A: Both. Bad habits are hard to break, as we saw at Washington Village. But there are still too few options for primary medical care – and that number is dwindling relative to the need in the population. Increasingly, doctors are being discouraged from going into or staying in primary care. The skyrocketing cost of medical education, along with the high cost of maintaining a medical practice due to government regulations, makes it impractical to go into the lowest-paying specialty, which is primary care. The most recent insult: The Medicare primary care bonus is slated to expire at the end of this year, in effect rendering a potentially devastating 10 percent cut in Medicare reimbursement to primary care practitioners.
As for coming up with disincentives to going to the ER and using the providers that do exist, no one has yet figured that one out. A real solution would entail total revamping of the healthcare delivery and finance systems. Obamacare is not that revamping. All it’s doing is determining who is and isn’t insured and how much they pay. It’s not healthcare reform; it’s payment reform. As Democratic Senator Patrick Moynihan pointed out over 20 years ago in response to the Clinton initiative: “There is no healthcare crisis; there is an insurance crisis.”
Q: Health Maintenance Organizations (HMOs) were big in the 1980s. Wasn’t that a new way of delivering care and saving money in the process?
A: People living through the 1980s saw the opening of HMOs across the country, a concept that had already become familiar on the West Coast (i.e., Keyser Permanente in California) but was new to Baltimoreans. The HMO Act, which Congress passed in 1973, initiated millions of dollars put into this new, supposedly cheaper, healthcare coverage. Timonium Medical Center, where I was working at the time, and many other centers around Baltimore, adopted this model.
HMOs seemed to be the answer, because of the concept of “risk sharing.” Insurance companies – including Medicare, the government insurance company for seniors – would allot a set amount of money per patient to doctor groups, thereby putting a “cap” on spending. This money would be divided up into allotments for primary care visits, specialist visits, and hospitalizations. A percentage of what each doctor group didn’t spend on patient care would go to their profit. If they used up the allocation, either the doctors or center owners or both would lose money. As new managed-care plans mushroomed, many employers perceived managed care as less expensive than individual insurance and stopped offering a choice of plans.
One big issue I had with this model (as I saw it implemented at Timonium) was the philosophical/ethical problem it posed. Assigning the primary care doctor as the gatekeeper of the purse put the goals of the HMO – financial sustainability – in direct contradiction to the medical ethics physicians are committed to uphold. I, personally, refused to consider the allotments, and treated patients as I would irrespective of the allotment status, even if that meant I didn’t get a bonus.
The overarching problem was that there was no alignment between the practice model and what real medical practice entailed. For example, the bean counters at the insurance companies wouldn’t know that spending more now on a costly exam by a specialist might save three times that amount spent on a future hospitalization, not to mention reducing the pain and suffering of a patient. However, the model attempted to limit what could be spent on specialists, potentially punishing both the primary care doctor and the patient.
This is a problem that occurs when bureaucrats attempt to manipulate medicine (or most things about which they know little). Colleagues and I came to refer to managed care as “damaged care.”
As an aside, our center was bought and sold six or seven times by different groups for different reasons, but each left within a couple of years disappointed. Today, the only ones interested in buying a primary care medical practice are hospitals – for the practice’s potential to fill their beds and use their facilities, such as labs, physical therapy department, and outpatient surgery, etc. Another little bureaucratic tidbit: Medicare reimbursement is slightly higher when paying for care done in a hospital-owned practice, a nice bonus for the hospital.
Q: What happened to HMOs and to healthcare – or insurance – reform in general?
A: The HMOs died a natural death. You may have already guessed part of the problem. For a system like this to work, you need a patient mix that is predominantly healthy. What happened at Timonium was that many of the healthy, young, and more affluent people opted out. They wanted choice over which doctors they could see, an option that the HMO plan, in exchange for the lower premium, didn’t offer. The sicker elderly signed up, eager to take advantage of all the (over) promised benefits for one set price, and they were willing to give up choice for affordability. The system couldn’t survive without those healthy participants paying for but rarely using the services. The HMOs that have done well are those that are able control every aspect of the plan. Like Kaiser, they own the hospital, employ all the doctors, including the specialists, and in so doing are better able to control costs.
With HMOs gone, the government sought new ways to save. You may recall that healthcare reform was a number-one priority of President Clinton (1988 to 1996) with Hillary named to lead the charge. In a congressional address on Sept 22, 1993, President Clinton asked Congress to support the plan his wife had generated “to fix America’s broken healthcare system.”
Hillary did come up with a complex proposal, over 1,000 pages long. This plan mandated that employers provide healthcare to all their employees, and required all citizens to enroll in an insurance program or be penalized. Sound familiar? Congress rejected it as too bureaucratic and unwieldy, impossible for anyone to follow. (In fact, there were lawsuits against Hillary Clinton and then-secretary of Health and Human Services, Donna Shelala.) That bureaucratic nightmare of Hillary’s just needed a couple of decades to get used to. In 2010, Congress voted a similar plan into law (without reading all those cumbersome pages) and called it the Affordable Care Act (ACA), colloquially known as Obamacare.
Just as with the HMO model, success for Obamacare requires having a good mix of people: the healthy along with those with chronic health problems, like the elderly. The difference between them is that with the HMO, you had a choice, whereas, with Obamacare, you don’t; you must have insurance. With fewer full-time jobs available and fewer employers offering healthcare, more people (the young and healthy along with the unhealthy) are facing difficult choices.
A big problem with the ACA – an unintended consequence of its onerous mandates and cost – has been the growing number of loopholes for people to opt out. Congress itself was the first group to opt out. Employers have reduced employee hours to avoid the expense of covering 50 full-time workers. With each group opting out, the premiums for those remaining in the system go up to cover the deficiency. You may have seen that just last month, with year three of Obamacare underway, half of the nonprofit exchanges known as co-ops shut down, leaving half a million people scrambling to find what will likely be more costly alternatives. The Affordable Care Act has become a misnomer for many.
Q: You alluded to the idea of increased doctor dissatisfaction. What are some of the causes of that dissatisfaction?
A: If you Google reasons for physician dissatisfaction, you will see a factor that affects both the physician and the consumer: the advent of electronic medical records (EMR). The government requires all practices with government reimbursement – read Medicare and Medicaid – to use EMRs or be penalized with reduced compensation. These programs cost hundreds of thousands of dollars, not to mention the periodic “upgrades,” which cost money and time to relearn.
This is a burden on small practices, which, not surprisingly, you don’t see around much anymore. They have either merged, expired, or been bought up by hospitals.
The efficiency claim for electronic medical records did not become a reality. Another unintended consequence: The government mandated their use but did not mandate the vendors. As a result, different systems cannot “talk” to one another, causing the whole process to break down. The amount of time spent inputting data has gotten out of hand. Personally, I feel like a doctor half the day and a data-entry person the other half.
It’s not just about inputting data but also knowing the codes that correspond to a patient’s condition and are necessary for a doctor to get paid. The EMR program will help find the code, with additional refinement by the physician, but as the number of codes grows, it become more cumbersome and time consuming. These codes are known as the ICD series, and we have just recently been introduced to the newest incarnation, ICD10. ICD10 has 70,000 codes for different ailments and diagnoses, including ones for “under-dose of coffee,” “UFO sighting,” and “fights with mother-in-law.” Yes, all of these have a code (!) and are fundamental for reimbursement.
EMR is the bane of existence for many doctors today, forcing doctors to become part-time data techs. According to the journal Medical Economics (Feb 10, 2014), EMR is not only costly but actually contributes to the loss of physician productivity. One reader wrote, “We used to see 32 people a day with one tech; now we see 24 with four techs and provide worse care than before.”
One way that some doctors are surviving government intrusion is by creating a concierge practice. In this new phenomenon, the doctors open their doors to a limited pool of patients, each of whom is willing to pay $1,500 to $2,000 per year in exchange for a guarantee that the doctors will be available to them 24/7. With the infusion of $525,000 to $700,000 of upfront capital for a 350-patient practice – before even starting to bill insurance companies – these doctors have more options and fewer government constraints.
Q: It is estimated that somewhere between 20 and 50 percent of healthcare dollars are spent in the last six months of life. One of the things heard during the debates over Obamacare was the inevitability of so-called “death panels” in a system obsessed with cost savings. Have you seen any of that, especially given the elderly population you serve?
A: I haven’t seen any evidence of death panels. In fact, without a medical directive (either from a patient or proxy family member), we do everything to maintain life at any cost. Even though physicians have the right to deny care considered futile, none of us withholds care for fear of being sued by the patient’s family.
I make a point of discussing with a patient, when he is cogent and in reasonably good health, what options he can choose or refuse when death seems close at hand. When you can openly discuss the pros and cons of different options, you learn that many patients don’t want extreme interventions, especially as they get older. Unfortunately, most doctors shy away from that conversation. Sadly, when the end is near, some families tell us (inappropriately) to do everything possible, often in clinical conditions which are futile, and where extraordinary measures cause additional pain and suffering, usually don’t extend life, and may be contrary to what the patient would have wanted.
Medicare recently included in its 2016 budget coverage for “end-of-life counseling,” to discuss advanced directives and end-of-life choices. This positive inclusion won’t help patients if doctors have not been trained or have taught themselves how to have that important and very difficult conversation. Some may view this inclusion cynically as a way to pressure the elderly who don’t want to impose the expense of medical intervention on their family. I believe doctors want what is best for their patients; not having the conversation is more destructive to a patient.
Q: How have the changes you have experienced changed the way to you envision a career as a doctor? Would you do it all over? How do you see the future of a medical career?
A: Becoming a doctor seemed a good fit for my personality. I like people, science, and fixing things. I was also idealistic when I was younger and looked at medicine as a way to help people. My wife and I even thought we would live someplace where I could barter my skills: I would do a well-baby check up in exchange for a chicken and bunch of tomatoes. For most of my career, I have enjoyed being a family doc, and my interest in offering healthcare through the dynamic of the family has been met. I’ve enjoyed making the occasional house call when someone was too sick to leave his house, and getting to know the person more fully: seeing his home, meeting his family. I believe that good healthcare entails getting to know a person beyond just his immediate ailment. That requires spending time, which is something doctors no longer have if they want to survive. Our time is now consumed with data entry, learning new codes, taking exams with out-of-date answers in order to remain board certified. Many days I am at the computer as much as I am with patients. I’m not sure I would choose medicine again in this environment.
I don’t see things getting much better soon. There is now a new moneysaving idea being considered: outcome medicine. This would be a way for insurance companies to limit payment if the outcome is negative. Medicare already has a rule that it won’t pay hospitals that readmit a patient with specific diagnoses (e.g., congestive heart failure and COPD are a couple, and the list is growing) within 30 days of a previous hospitalization. One of the ways the hospitals are attempting to get around that ruling is by not technically admitting patients who show up within those 30 days. Instead patients are put in a bed for “observation” – which the patient pays for – until they are eligible for re-admittance according the regulations. Watch for the long-term unintended consequences of that one. (More lawsuits?)
I don’t know how the new crop of doctors and other primary care providers (nurse practitioners, physician assistants, etc.) will fare in the future. Maybe not knowing how good medicine used to be, they won’t be disappointed.
Jill Moroson Blumenthal is a social worker and rehabber of vacant City properties and has been having an ongoing conversation about healthcare with her husband for many years.