I am now old enough to reminisce about the good old days. Back in the Stone Age when I started my practice, I would enter the exam room with a paper chart and a stethoscope, greet my patient and then sit down and have a face to face interview. Once the interview was completed, I would have my patient sit on the exam table, do a thorough exam and then return him to his chair and discuss my findings and plans. My patient and I would agree on a treatment or diagnostic approach and I would give him a handwritten summary and walk him to the desk and say goodbye. As his physician, I did not have to ask anyone’s permission to order a test or prescribe medication. Prior authorization meant I authorized the treatment prior to his leaving the office. The only authority who could challenge my treatment was the patient; and, since the patient was involved in the decision, treatment could be started immediately.
Flash forward to today. On average I would apologize to 12 patients a day. While I still walked into the room and personally address my patients, I would be required to address the computer that sits on the counter as well. It is hard to have a personal relationship with an 18 inch monitor staring you in the face. Medicine in the year 2019 is all about recording details and clicking that ever present mouse and keyboard. Our government, the insurers and the lawyers all agree that collecting data is what it is all about. If you do your paperwork, you must be a good doc. So, I apologized for using the computer and would try, as best I could, to have a face to face interaction with a real person, as opposed to an 18 inch screen.
The patient and his/her doc are no longer capable of deciding, on their own, about diagnostic and treatment options. Insurers have usurped the docs’ responsibilities and require prior authorization before tests are performed or medications filled. Prior authorization means the doc authorize (write a prescription for) the test or medication that they then refuse to honor. Treatment is delayed until their staff and the doc answer a long list of questions proving to the insurer that you have failed on the insurer’s cheaper option or really, really need the test. If you have not “failed” on the insurer’s prescribed option, they may refuse to pay for your treatment forcing you, the patient, to either pay for the treatment out of pocket or risk failure. Again, my profession must apologize.
How or at what point your doc, a board-certified physician, and you, a patient in need of care, lost control of our own destinies is beyond the scope of this article. We, the doctors and patients of America, continue to see our autonomy and rights slip away. The very core of medicine, the patient-physician relationship, is under attack on every front. While I took care of the children of the children I cared for during the early years of my practice, it got harder for those patients to remain with me as their employers change their insurance coverage every year. Policies are becoming more restrictive. In the past, I should not have had to say goodbye to a patient like Bill, a patient of 27 years. His employer had just changed his policy to an “open access plus” plan that was so highly restrictive that I refused to be a participant in it. “Open Access Plus” sounds great, doesn’t it? I told BiIl I was sorry to lose a relationship that had grown strong over the last 27 years but I could not function under such a restrictive policy! Bill and patients like him will be forced to find new docs as corporate America changes insurance policies and procedures on a yearly basis and use the word open when what they are selling is anything but.
I am saddened by the changes in my profession that have occurred over the last 40 years. I am fearful that the data the government and insurers collect from my computer will be used to further compromise physicians’ abilities to practice personalized medical care. While there have been many good changes, I find myself apologizing more often than not to those who suffer at the hands of modern-day medicine.
I am torn between the sadness of no longer being in practice and the relief of no longer having to fight with the insurers, our government and the damn electronic medical record. I’ve always said that if you can make something good come from something bad, you can lessen the bad.
I am glad to be able to speak my mind and tell my audience how bad it has gotten and how much worse “Medicare for all “will be.