We received an email recently about a patient who was suffering from significant distress and got nothing but the run-around from her doctors. She had undergone extensive testing but was not given any clear feedback or results, and was basically let go with no explanation or significant treatment. Her son was very distressed and wondered, "What’s wrong with the system?"
My staffs’ response was, "We hear stories like that on the phone every day." Recently, I was lying in bed, feeling under the weather, and I had this flash – "What if I really got sick?" I suddenly felt the need to say to my wife, "If I’m ever unconscious, and you can’t wake me up, don’t call an ambulance. I would rather take my chances here."
On more than one occasion, I have said to a patient who was sick, “I don’t know any doctors in your area. You’re safer staying home than seeing a doctor at random.” The number of horror stories and irrational medical treatment that I have heard is staggering. While medical science is growing exponentially, satisfaction with medical care seems to be on the decline. What is going on?
There are undoubtedly many factors contributing to the problem. When I first started treating patients in the 60’s, patients presented with symptoms, and doctors did whatever tests they thought were necessary. Once a diagnosis was established, treatment options were discussed and the best treatment for that patient would be initiated. Follow-up would be determined according to each patient’s needs and treatment response. The insurance would cover whatever cost they were contractually obligated to cover.
Over time medical costs grew and insurance companies began to balk. A monitoring system was established as a new entity that would regulate medical care (aka “managed care” but really “managed cost”). They would take 20-25% of the medical dollars available, and in return, cut cost to both insurance companies and employers. Meanwhile, the employee/insured had 30% or more taken away from them in medical reimbursements and coverage.
Insurance 101: Did you know that there are people in this country today who believe insurance companies exist to help you? They exist to make money. They make the most money by collecting as much as possible in premiums and paying out as little as possible in claims. Insurance companies now have the most power. “The tail wags the dog.” Of course, they make a lot of money and contribute generously to politicians. It’s the “golden rule” – “Him with the gold is him who makes the rules.”
A case in point – I evaluated a young woman who ironically worked for a large insurance company. She was severely depressed and although not needing hospitalization, needed a lot of therapy along with antidepressant medication. Her insurance only covered “approved therapists” on their list. I said fine but I would like to see the list so I could suggest a therapist that I had a relationship with so we could coordinate her care. They would not share the list. They informed me that therapists were selected who had more of a short-term therapy approach. How was this established? Well, how many times would a patient go back to see them … if they saw them only once – that would be the most effective therapist. If the went back 12 or more times, they obviously were not short-term oriented and would be presumably dropped off the list. You get the picture.
How does this impact the treatment of a given patient by a given doctor? Most doctors who do procedures that can be very costly have to deal with insurance companies. Myself and other psychiatrists and few other doctors have opted out of insurance plans because medical care of patients is often adversely affected by restrictions in time, frequency, type of appointments, etc. I still have to deal with insurance companies at times to get prescriptions approved, and that can be a nightmare. Recently, I had a patient who had excessive daytime sedation and was in jeopardy of being fired. The only medication that worked for her was Provigil. She couldn’t afford it. The insurance company refused to cover it despite the strong letters of appeal.
Insurance companies may be quick to pay $1000’s for highly technical procedures but won’t pay for 15 minutes for a doctor to counsel a patient about weight, smoking, etc. They frequently won’t pay a primary care doctor for services related to treating anxiety, depression, and insomnia even though they provide the bulk of this treatment.
One of the most harmful consequences of this shift to insurance company domination is that by gradually reducing what they pay physicians, physicians gradually decrease the amount of time they spend with patients. Medical office overhead is very high, and doctors have to generate a lot of cash flow to cover all expenses. I’m not talking about super-specialists with very expensive surgeries or procedures – they’re doing fine.
Recently I was speaking in a primary care clinic, and I asked a doctor how he evaluated for depression. He said, “I used to have them fill out a check list of symptoms for depression, but now I don’t have time. I just note whether they’re tearful or look depressed.” Unfortunately, only 70% of people who are clinically depressed report feeling sad, down, or depressed. 30% have other symptoms, especially loss of interest, motivation, or pleasure (85-90% of depressed patients). I guess they’re out of luck.
Doctors don’t have enough time to adequately evaluate or counsel a patient. Insurance companies usually won’t pay for a clinical assistant to help. The system is broke! I’m not sure what the solution is, but I’m sure it’s not the government.
People have to take more individual responsibility to research their symptoms, diagnoses and treatments. They have to network and do everything possible to find a physician who takes the time to listen and address their concerns and then provides either adequate care or refers them to someone else.
All fields of medicine are going to get increasingly complicated and expensive. I’m afraid things are going to get worse before the pendulum begins to swing back.
