Dr. Steven Ringel, a neurologist at the University of Colorado School of Medicine, recently wrote a paper in Health Affairs entitled Practicing Medicine Versus Pushing Paper. In this article, Dr. Ringel describes his daily responsibilities with regards to paperwork and phone calls he must attend to in-between and after seeing patients. I urge you to read this paper to get a full sense of the incredible burdens we place on our doctors because we accept the system’s status quo. By that I mean, we accept making doctors divert their attentions and we accept questioning their medical judgment. We need to let doctors focus on their patients, we need patients to be involved in their care, and we need to create a culture change so that we don’t accept the way things are.
I realize that there are a lot of efforts out their to “change” our health care system. The Affordable Care Act proposed so many new pilot projects, endeavors, incentives, etc to ostensibly improve care. Politicians fight endlessly on how to reform the system. But most of these efforts (on either side) don’t actually address what’s wrong. Some will help (like health information technology) – but even most of those won’t help immediately. The rest are just there to make us think we are making change, but really are deceptions (like Accountable Care Organizations and making doctors report more quality care measures). The real problems remain and part of those include doctors pushing paper instead of practicing medicine.
We very much undervalue the amount of work we ask our doctors to do. As you point out, filling out forms, returning phone calls, fighting with insurance companies, explaining insurance benefits, while keeping up on new research. We ask you to do all of these things without compensation or acknowledgement. Unfortunately, the burden will remain on doctors and will only increase with new regulations, incentives and projects under the Affordable Care Act. Instead of actually improving care, we allow the status quo to continue, and the status quo will remain until we change the mindset in our culture that it is not acceptable.
It would be nice if patients could take more responsibility for their own care. Patients should not be responsible in the sense that they coordinate billing or demand medical tests they deem necessary. Rather, patients should be taught to advocate for themselves vis-a-vis their insurance companies and the administrative barriers complicating their ability to get access to care they need. Patients need to know who the can ask to talk to, what they should ask for, and what information they need to provide when communicating with their insurance company. If patients (or their family members) can advocate for themselves, it could ease some of the burden of the doctors entrusted with their care. We could make patients and doctors allies in pursuit of health. Sadly, this is probably too tall an order to ask. The system is too complicated and it’s meant to be that way – so patients will get confused and give up.
Even if patients can advocate for themselves, it’s not enough. Doctors are left with an insane amount of work, patients are left confused and upset if not without the medicines and care they need, more money is wasted, more time is wasted, and health care is compromised. It’s ironic that in trying to save money and ensure quality care, we actually make things worse. Some think if we have all the quality measures reported and pre-authorization papers and order forms filled out just so that the “system” will be more efficient and better. But it won’t.
We all know that the “system” doesn’t work. Yet, the nation created this “system” and is unwilling to change it as it needs to be changed. We have yet to create a culture that won’t accept the status quo. Perhaps in part because we rely on doctors to navigate it, and they do. Maybe in part because we don’t ask patients to be involved in that part (I’m not sure we can), and if they aren’t as involved, they can’t know how dysfunctional it is, or who to blame when things go wrong.
I myself briefly represented the indigent, the sickest of the sick children in appealing Medicaid denials, working through the administrative barriers and assisting doctors and providers with their responsibilities to ensure children with illnesses and injuries you cannot imagine stay healthy. Yet, even these efforts aren’t enough. We are so underfunded and overloaded with cases, we can’t even begin to fight the system for changes. We might get a Medicaid denial overturned, but the next month when the same forms for the same request for the same child are filled out, there will be yet another denial to appeal. This means doctors spending more time on paperwork, children going without care, their caregivers not knowing where to go or what to do and money and time wasted. When I talk about appealing Medicaid denials, most think – well of course they were denied to prevent fraud and abuse. Because fraud and abuse are all the public know about the system. Again, we haven’t created a culture that realizes that health care shouldn’t be run this way (by the government or private companies) – asking doctors to fill out needless and endless paperwork and questioning their professional judgment all to avoid some supposed fraud or wasted spending.
The question is – how do we create that culture of change? How do we really help Americans (and more importantly) legislators see that asking doctors to practice medicine AND push paper is not acceptable? We start by understanding what we ask of our doctors (by reading articles like the one above), we ask patients to be involved in their care, and we put pressure on those in power to make real changes. In the meantime, advocates and doctors keep fighting to do the best they can, despite the obstacles and work to show that our health care system can be better than this.