Tales of a Family Doc.....a year later

Cross-posted at DKos

My professional life is full of stories.

There are some of remarkable bravery and happiness: Just last Friday I had the opportunity to trade emails with a patient who, finally, in his 60s (!) has managed to overcome drug abuse, alcoholism, crippling self-doubt, hypertension, and diabetes (yes, he managed to get off all medications!) through hard work and determination.  Another, a recently retired Greek American burdened with obesity and its complications, arthritis, diabetes, high cholesterol came in to have me guide his discontinuation of his medicines after his health improved because he returned to a lifestyle "like I used to do in Greece."

This essay supporting radical transformation of the health care system weaves anecdotes from clinical practice with hard policy analysis. Another version was published here ten months ago, but the passage of time and events demanded an extensive revision.

And there are some tales full of woe, which can bring me to tears:

About three weeks ago a thirty year old patient whom I had not seen for many years came to my office. He had a large testicular mass, something he ignored until it became painful, not because of youthful imaginations of invulnerability but due to the absence of health insurance.

Now he's in trouble. Although testicular cancer is one of the most curable cancers, even in advanced stages, treatment is expensive.

And not only is my patient in trouble--bankruptcy is a given--, but the rest of us are in trouble, too.

It would have been so simple, had we a universally available national health program, to treat him with minor outpatient surgery months ago, but now he, and we, are in for the big time.

It makes me want to cry.

The day to day work is full of mundane stories as well, which have their own lessons....

It was 8:50 a.m. when I arrived at my office to find Glenda, my office manager, buried in charts.  She'd been there since 6:30, arranging referrals that had been requested the day before, making sure that the detailed forms required by the Child Health and Disability Prevention Program which pays for preventive care provided to some of our poorer patients had been properly completed, and listening to voice mail from pharmacies in order to get medication refill requests for me before the day began 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 a distant suburb, arriving early to avoid rush hour gridlock and get some 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.  In her early morning work Glenda joins in what I think of as a game of "hot potato." 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 work back to the doctors.

The administrative work forced upon medical providers by the private health insurance bureaucracy is almost beyond belief. Indeed, a recent study supported by the Robert Wood Johnson Foundation found that 6.9% of all physician expenses (exclusive of billing costs!) are directly related to burdens imposed by dealing with these corporate bureaucracies.

My own 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, caring for my hospitalized patients, but always spending most of my time seeing patients in my office across the street from the hospital. Over time, in order to make sure that I could take vacation and to spread the overhead, the practice has expanded and now we are a group of five part time physicians and two nurse practitioners supported by seven full and part time staff.  I am in the office four days a week but have managed to work it out so that I am in by 9AM and usually out by 3 or 4PM. The shape of my day is heavily influenced by administrative tasks, however.  On a typical day I spend about an hour dealing with tedious, medically unnecessary tasks imposed by insurance companies.

Shortly after I arrive and begin to call 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 had used when completing a lab order form.  Some insurance companies, it turns out, do not pay for preventive screening tests, so when I order a cholesterol or a prostate cancer screening test at the time of a health care maintainence evaluation, the test might 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, knowing that the insurance company will not balk at payment.

In our office we work primarily with two labs which between them are contracted with nearly all the insurance companies we deal with.  The hospital-run lab is the most convenient, and we are required to use it for about half of our patients.  The other lab must be used by a small fraction of patients. Medicare patients and those with certain PPO insurances, can go to the lab of their choice but choosing one lab rather than another may result in a much larger bill for some patients.  For this reason we have a special deal with one lab where we've been given a list with prices far lower than they charge patients when they're billed directly.  That way, when we order a test that may not be covered by an insurance policy or if we are serving an uninsured patient, we can collect the discounted price up front and then the lab bills us rather than the patient.

Unfortunately, one of the charts Glenda brings presents a little laboratory headache. Bridget Hanley (her name and the names of all patients in this essay have been changed and the details of medical conditions slightly altered to protect privacy) sent in her 21 year old daughter a few months ago for a routine physical.  During the course of the evaluation, a few tests were ordered.... a Pap smear, some S.T.D. tests, a cholesterol test, and two hormone tests.  Unfortunately, because her insurance had changed, the "wrong" lab was used and Ms. Hanley got a bill for over $1000.  That's a lot of money to the Hanley family and she is rightly annoyed.  I am too: at the lab’s outrageous markups (if we had used our "special deal" the charges would have been only about $200), at a system which forces me to have to consider which lab is "appropriate" for which patient, and at Ms. Hanley.  "Isn’t it her responsibility to know which lab her insurance requires her to use?" I think, upset that she was annoyed at me for this mess.

Conservatives argue for the role of personal responsibility in health care.  The Hanley family dilemma, and mine, however,is that health care and health care finance, even of the routine variety as in this case, is complex and removes the recipient of services (the patient) from the one prescribing services.  In emergency cases, the patient is even less able to participate in choice. This is part of the reason why conservative principles of health care reform are so divorced from reality.

Nevertheless, I sit down and send my second email to the lab director pleading for her intervention in seeking a reduction in charges.

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 my own practice I deal with over one hundred!) in this country introduces an administrative mess beyond belief.  Our small office of essentially two full time equivalent providers requires seven support staff to cope with the complexities of this system. I am quite certain that the wasted effort which 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.  

By 9 a.m., the receptionist, Alba, comes in.  She is the newest member of our staff, brought in only when our primary receptionist, Evelyn, became ill,  requiring extended medical leave for breast cancer treatment at the same time as another staff member was scheduled to be out for maternity leave.  So the office is operating a bit understaffed these days.  Fortunately, Evelyn’s health insurance is through her husband’s large employer. He works as an animal care technician for a public university medical center.  As long as he works they are covered.  I try not to think what would happen should budget cutbacks lead him to lose his job.  The prospect is frightening for her, for her family of four, and for our office.  I certainly would feel obliged to add her to our office health insurance program should this occur.  But would the insurance company accept her?  What would happen to our premiums? Even assuming no rate increase, adding her to our policy would amount to about a six dollar an hour raise.  And what about coverage for her family?

In the ten months that have passed since the first draft of this essay was posted our insurance premiums have risen over ten percent.  As a response, I've dropped our high quality HMO coverage and have substituted a PPO plan with a large deductible.  My hope is that my staff will remain healthy, saving me some money, but I have promised them, in making this switch, that I will cover their deductibles, taking a risk that my own out of pocket expenses will grow significantly.

Another update:  Since the original version of this essay was posted Evelyn has remained healthy, free of recurrent breast cancer.  Alba, the receptionist who stepped in to fill her place, has moved on, and a new staff member has joined us.  This latest member of our staff consulted with me today because of an illness that would usually have led me to order several laboratory tests and an ultrasound. Instead, she and I are going to hold off, hoping the illness will pass on its own as she only recently was rudely awakened to the limitations of a bare-boned insurance policy she shares with her husband and the prospect of more medical bills seemed worse than the anxiety of not knowing just how serious her illness might be...

The receptionist's job requires verification of each patient’s insurance status, checking lists, looking on-line, and calling for approvals as she confirms insurance eligibility and documents changes.  Missing an insurance change can have costly implications for both patients and our practice.  Between changes in jobs and employers changing insurance plans to save a few dollars in premiums (as I have recently done), there is a surprising amount of "churn" among health insurance carriers.  For Alba, learning the details of this part of her new job was quite a challenge.

The three medical assistants on my staff spend hours daily communicating with patients about medication refills and calling or faxing pharmacies.

Recently we have moved from faxes and phone calls for refills to electronic prescribing. Although we have not seriously considered a wholesale adoption of an electronic medical record, this first step, which would consolidate all our refills in one system and which would eliminate the need for filing seemed worthwhile.  It has been a moderately difficult transition, adding to the workload of the providers although reducing the workload of the support staff.  Certainly, our experience with this, the easiest and seemingly most cost-effective aspect of the electronic medical record, doesn't suggest that electronic medical records will lead to any significant savings in health care costs

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 must 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.  

A serious related economic issue for our office sprang up last year.  One key physician associate decided that she was feeling overwhelmed by her patient load and so decided to close her practice to new patients.  This is a more complex and consequential process than it seems. Contracts with insurance providers often require an open practice or establish tiers of payment based upon whether a practice is open or closed.  Further, in closing a practice, a wheel begins turning so that the closure is indicated in published listings and on-line resources.  This process can be slow and then difficult to reverse.  Years ago I had closed my practice for similar reasons.  When volume dropped, I attempted to re-open.  Some insurance directories, however, lagged in updating these changes for years, leading to much frustration and some degree of financial hardship.

When my associate decided to close her practice, we settled upon closing only to those patients "provided" through our local independent provider association, an organization which manages insurance company contracts for doctors in our area and with which we have a good working relationship.  Gradually, over the course of a year her patient panel from this source dwindled from 1200 to 800 patients.  At that point, feeling the pinch of lost income to the practice, I asked her to reopen her panel.  We are largely paid by capitation, "per member per month," from these providers so this source of income had dropped by about one third.  She was shocked and appalled by my request.  Despite the closure of the practice and the substantial loss of income, her workload had declined only slightly.  How had this happened?

What we had experienced through this closure was the shock of"adverse selection".  By closing her practice to new patients, my associate lost from her capitation list those patients who bounce in and out of insurance, often healthy and more mobile people who don’t have regular need to see a doctor.  With capitation, payment is based upon the number of patients assigned to a doctor rather than upon the nature of the care required.  She was left with a group of patients who tended to be the ones who see her more regularly.  Hence, less income, same work.    

Of course, this process is something that private insurance companies play in reverse.  A great deal of insurance company money is spent attempting to avoid patients who could actually require medical services.  Underwriting, the process of selecting which individuals and business clients to insure and varying charges based upon assumptions of how much those clients will use their insurance is the backbone of the insurance industry.  Marketing, the process of selling insurance, has become a primary tool of this process.  Has there ever been an insurance company advertisement that encourages patients with serious chronic illnesses to sign up?  Instead, television ads depict elderly men walking on the golf course.  The idea is to create a "favorable risk selection", patients signing up for health insurance who are unlikely to use it, leaving  those who need it to some government-provided "safety net" or left to fend for themselves, uninsured.

My first patient of the morning was Uluake Tonga.  His English is not great, but we can get along.  We have known each other for nearly 20 years. Like most of my Tongan patients (there is a surprisingly large group of this nationality in this part of the San Francisco Bay Area) he comes with a family member who can help him translate.  His history is complex, as are his medical needs.  Briefly, he has diabetes and most of its complications.  Mr. Tonga has never been good at working with the medical system. A hard working airline food preparer at the San Francisco airport, he had for years denied his diabetes.  He believed in some natural medications and failed to see me very often.  I’d long suspected that the expense of conventional medication was part of the issue as he had insurance of the sort that required him to pay a significant deductible every year and when I took over his care from his previous doctor I noted that his chart had "sent to collections" stamped on it more than once.

Mr. Tonga first faced his diabetes in a serious manner when he was hospitalized for a vision threatening fungal infection.  Soon afterwords, because of layoffs in the airline industry, he was without insurance and decided to return to Tonga for a few years.  Medical care in Tonga is free and while in the South Pacific he did get care for his diabetes and his blood sugar was finally controlled. Nonetheless Mr. Tonga returned with progressive disease.  Now, with kidney failure requiring dialysis, he is better about compliance with his care.  Maybe it is because the gravity of his disease is too much to ignore, but I suspect a lot has to do with the fact that his kidney failure now entitles him to Medicare benefits.

Medicare and its cousin, the Veterans’ Administration health system, contrast markedly with the bureaucratic inefficiency and buck passing of the private health insurance system. These systems, which share the fundamental features of centralized funding and near universal enrollment of the populations they serve, have shown that they can provide better quality care and higher satisfaction at a substantially lower cost than the private health system. Within these systems there are no resources spent on achieving a favorable risk selection, marketing, underwriting, investor relations; nor are there corporate profits.  As a health care provider, when I deal with Medicare I operate within a clear cut set of rules that applies to all my patients, making referrals, prescriptions, etc. easy to accomplish.  

When I see Mr. Tonga, or any of a multitude of other patients whose care has been compromised by the complexities, gaps in coverage, or the increasing unaffordability of private health insurance I wonder about alternatives.  Increasingly, I have discussed these alternatives with my patients.  During the course of an office visit or speaking to a patient over the phone problems which relate to the inadequacies of the health care system often arise.  In a typical day there might be four or five opportunities to discuss issues related to health care reform with my patients.  Yet despite the number of different health care financing reform proposals that are bandied about these days virtually all of my patients gravitate towards the same approach:  a simple and comprehensive health care plan paid for through taxes and provided through the network of private providers with whom they are familiar. Hundreds of my patients have signed a petition to this effect which I leave to speak for itself in my waiting room.

From my end, as a physician and small business owner, eliminating the multitude of rules, the files of thick contracts, the variations in co-payments, deductibles, and  formularies, no longer needing to tell patients that they can’t see the provider I’d recommend because their insurance doesn’t allow it, seems like a dream come true.  I want to be confident that my employees have access to quality medical care, that I won’t have to be out shopping for a new plan next month, and that I won’t have to choose between a raise or medical benefits for my medical assistant’s newborn when she returns from maternity leave this winter. (Update:  She managed to get insurance through the father's work!)

But how do we get this done?  It doesn’t take much thinking to realize that the only proposal that makes sense to get what is needed is a single payer plan, a Medicare-For-All.  Other proposals, health savings accounts, consumer directed health care, managed competition, employer mandates, individual mandates or variations on these themes all promise benefits but suffer from failing to have the potential to achieve true universal coverage and from being hugely expensive because of their reliance upon private health insurance. While some of these variants have been subject to experimentation in the United States (the Massachusetts plan, most notably) only a single payer approach has been shown, in both the U.S. (Medicare) and abroad (throughout Europe and Canada) to work.

In these pages over recent months the dialogue has shifted from advocacy of a single payer system to support for a public option.  I have certainly written also in support of a public option.  But it is clear to me that anything short of a single payer plan will be destined to fail at achieving anything close to universal coverage and will lack the power to do much to bring health care costs under control.


A publicly financed decentralized system of private health care that is not tied to employment or "category" could eliminate the waste in the bureaucratic private health care system and eliminate the multitude of compartmentalized public and private systems which currently pay for segmented components of health care.  Imagine!! No need for Medicaid, MediCal, CHDP, SCHIP; a reduced scope for worker’s compensation insurance, medical liability insurance, and automobile insurance; human resource departments downsized.....the list goes on and on. Essentially, as an improved Medicare for all, this reform would eliminate the distinction between health care for the poor and health care for the rich and reduce the confusion, waste, and annoyance which my office staff and I face in dealing with so many different health insurers.

Something is missing in our political debate over medical care.  Over and over again I’ve heard people in power or those writing about the issue support the logic of the argument for single payer reform and then dismiss it without much consideration.  Barack Obama has supported this change in theory, but adds that we have to begin from where we are.  Jacob Hacker, the Yale and Berkeley political historian who is the intellectual champion of the public option, seems resigned to the observation that fundamental change is just too hard.  His Healthcare For America proposal reaches towards a single payer system but undermines its cost-savings and universality by keeping a huge role for private insurancee.  

A telling comment came from a member of the President’s Council on Bioethics, during their review of the ethics of health care reform proposals.  After commenting favorably on the powerful arguments with which he had been presented he demurred that these were "arguments that we are entirely incompetent to evaluate".  Another commissioner supported the notion of single payer reform but wondered, "if it’s not realistic in this country."   Even among advocates on the progressive side of the political spectrum there is a resigned assumption that single payer is somehow just too much of a change for our country to accept.

From my perspective in the trenches of primary care and small business, however, I can see no other way forward.  For my well-insured patients, a switch to single payer will hardly alter the face of the health care system they currently experience.  But it will reduce everyone’s level of economic and health insecurity.  None will need to worry if something is covered.  There will be no more holding on to unsatisfactory jobs simply to keep insured.  The process of paying for care will be simplified.

As a small business owner, I won’t have to worry either.  Some tax will be paid, a payroll tax, a value added tax, whatever .  But there will be no need to agonize over the question of which plan to choose and no more health insurance expense.  As I look at my office budget, the $36,144 that I currently spend on employee health insurance  is less than the $44,498.97 that I calculate would be owed under a tax of the magnitude contemplated by authors of single payer reforms. But when I add in reduced insurance-generated paperwork, reduced billing costs, lowered malpractice and other insurance premiums, and an increase in my own efficiency, this sounds like a reasonable deal for me as an employer – even without considering the improved care it would give to my patients and the increased mobility it would give to my employees who might seek to improve their lives by changing jobs.

A ray of hope:
Within the current debate there have been two places where I have found a ray of hope for real change.  One is in the Kucinich amendment to HR 3200. This amendment, which would remove federal barriers to state enactment of single payer reform, passed the committee with bipartisan support, Republicans backing it perhaps out of a desire for "states' rights".  
The other ray of hope actually lies in a related reactionary response to the health reform bills in Congress. Around the country Republicans in state legislatures have attempted to pass measures which would outlaw the individual mandate to buy insurance.  Although designed to scuttle a crucial aspect of the health reform bills this effort could pave the way for a compromise on the Kucinich amendment, perhaps with a provision that states need not participate in the health reform process as long as they provide an alternative program that secures health coverage for 100% of their citizens.

From where, then, does the political and academic reluctance to embrace single payer reform derive?  There would be losers, of course, and this generates some focused opposition.  The health insurance business would be essentially eliminated, perhaps surviving as a remnant to serve as a data collection and money disbursement system.  Pharmaceutical companies and medical device manufacturers might feel the pinch of tough negotiations from a central purchasing center.  But the interests of patients and health care providers of all sorts are sufficiently aligned that having a single payer should not prevent us from getting the health care that we need.  Certainly the experience of other developed nations with national health insurance supports this conclusion.

The last great attempt at achieving a major overhaul of our national health insurance system-- the Clinton administration’s reform effort-- foundered for many reasons: It was developed among a group of interested parties, largely outside of the public eye, creating the impression that it was beholden to "special interests".  The plan was immensely complex and required the creation of new agencies to oversee the program which could be portrayed as "big brother"-like control.  This, together with provisions that employers must purchase private insurance for employees raised fears about potential costs.  Small business owners who have increasingly avoided purchasing health insurance for employees perceived themselves to be losers, while already insured employees in larger businesses feared the specter of managed competition and the reform proposal’s focus upon cost control would result in lower quality and reduced choice.

The wheel has turned, and President Obama has taken a more open approach to health care reform. Yet though the crisis has deepened, and the solution seems clearer to those who understand the fundamental failings of our existing system, I am sadly doubtful that we are moving in the right direction.  The openness has let powerful private economic interests take control of the reform process.  In the next few weeks we will get a glimpse of what may be to come.  Let's keep pushing for and speaking the truth.


Aaron Roland, M.D

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