Can Fragmened Medical Care Be Fixed?
Last week I wrote about the symptoms and consequences of fragmented medical care. I was happy my readers raised a number of good questions, most importantly, is there anything we can do about fragmentation?
Thirty and forty years ago, there were many doctors in private practice. Some doctors worked in small groups of 3, 4 or 5, but there were also doctors in larger groups who still managed to avoid fragmentation of care. At that time, the obstetricians stayed together. The surgeons and internists stayed together, and then there were some sub-specialists who practiced from group to group. Doctors were collegial; they were friends. They respected each other and each doctor knew another doctor would pitch in to help if needed. I was called several times a week to assist area doctors with difficult deliveries.
The idea of partnerships with patients was real and practical. Partnerships with our patients were the glue that held together all of the aspects of their medical care and prevented our practices from descending into fragmentation. For most of my adult life I have either been in independent practice or a member of a small group. A while before I retired I began working in small rural hospitals. In these rural hospitals I could continue to practice medicine as I always had and maintain a relationship with my patients. I would see my patients in the clinic and I knew them well. I knew their careers, where they lived, their families, their fathers, mothers, brothers, sisters, uncles, aunts, nieces and nephews. I knew their past medical history without even having to open their charts.
Above all, when I saw them, I knew who they were, and I actually enjoyed taking care of them. I was reasonably certain they would follow my advice when they got home. I could explain their choices in language they would understand and could be reasonably sure they would comply with the treatment.
In addition to knowing my patients from their clinical experience, I would sometimes see them in the emergency room at 10:00 at night or 2:00 in the morning. If they were admitted to the hospital, I took care of them during their stay. Sometimes I sent them to a larger hospital for services our rural hospital couldn’t provide, but I likely had arranged the transfer to a physician I knew in the distant hospital. I knew when the patient was released from the larger hospital and would have access to the release care plan. And be sure any follow-up appointments were scheduled.
Enter the Henry Ford model of medical care. While assembly lines might be good for building automobiles, they are not very good for patient care. But every year we have yet more assembly lines. We have urgent care and walk-in clinics where you might see a doctor for a hangnail, a cut on your finger, or a sore throat.
And you have clinics which require a relationship with one of the doctors in order for you to get an appointment to discuss more complex problems. Getting into one of these clinics may require waiting several weeks for an appointment. And of course, you will have to be sure you are going to the clinic designated by your insurance or your accountable care organization.
My daughter has worked for one of these large medical corporations. She took telephone call once a month. In other words, she took call one day a month. She went to neither the emergency room nor the hospital. So, if she sent one of her patients to the hospital, she would not see her patient again unless the patient made a follow-up visit with her. Or if one of her patients went to the emergency room, she would not be informed unless the patient comes back to the clinic to see her.
Then there’s the hospitalist. The patient’s primary care physicians are prevented from caring for their patients in the hospital. Most hospitalists have a shift like an emergency room doctor. They might be on for 12 or even 24 hours but then for the next 24 or 36 hours they don’t go in.
The employment of hospitalists has nothing to do with quality of care and certainly creates even more fragmentation of patient care. As an employee of the hospital, the CEO and all of the other supervisors in the hospital have absolute control of the hospitalist.
When my patients see me on a follow-up visit from a large hospital, I am not at all surprised when they have been hospitalized for 10 days but can’t tell me the name of any of the doctors who saw them. Often there’s apparently no one responsible for how this patient manages after leaving the hospital. Diagnoses and plans for the patient are usually conveyed from one social service agent to the next with no regard for providing diagnosis and discharge information to the primary care physician. It can take hours on the phone to track down this information.
In the last seven years, I have seen one very notable exception to the fragmentation so common in large hospitals. The chief surgeon at the University of Minnesota gave a card to the patients I had sent to him with his personal name and his personal phone number. I was certainly pleasantly surprised. By accident I found him on LinkedIn and thanked him. He said as a student, he learned the value of the patient partnership. So, if the chief surgeon at the University of Minnesota can form a patient-partnership with the patients sent to him, then it should be possible for any physician to do the same thing.
Years ago there was this song about roller-skating in a buffalo herd. Sometimes I have felt like I was roller-skating in a buffalo herd. I told you in my previous Substack post about the problems my friend was having with fragmented healthcare and at one point he said, “I don’t know how you could stand it. Now I know what you’ve been doing all these years.”
I recently heard from one of his providers about how difficult my friend was to deal with. Yes, he can be difficult to work with, especially when he is being seen by several physicians who do not seem to know what the other one is doing. As physicians, we are not allowed to judge the behavior of patients. We have no business telling a patient they are rude. Badmouthing a patient with other staff instead of taking care of patients is not an option.
And then, of course, there’s the fragmentation of health care information with the electronic medical record (EMR) system. Many people do not realize that all EMRs are not the same. I’ve seen Epic be quite good and I have seen it be quite bad. EMRs apparently are adjustable and can be custom-made for each system. If that’s the case, physicians should have some say in how the EMR they use works.
Because the EMR system I last used was extremely unorganized, important information got buried never to be found again. Few people will look for something they don’t know is there. Reading the EMR is like trying to read confetti. There are detailed portions of information that are unrelated to anything and you would have to look very hard to find them. I would repeat a note that doesn’t change, in particular important notes physicians should look at every time they see a patient. I was criticized severely by medical records because I “cloned” my notes. If the chart had been reasonably accurate I wouldn’t have needed to repeat information in the notes to be sure the information was seen on every patient visit.
As I’ve said before, recognizing the causes of the fragmentation is relatively easy. However, the two large forces responsible for fragmentation are not going to disappear. I don’t see any way to tighten up the problems of physicians employed by large hospital systems and the problems caused by EMRs.
There is one small ray of sunshine here, and that is direct primary care. For a doctor who wants to be committed to a practice and committed to partnerships with patients, direct primary care is a good choice for patients.
The disintegration of medical care began in the 1960s with the introduction of Medicare. That’s when the American Medical Association (AMA) agreed with the government to allow Medicare to set physician reimbursement rates. No other professional organization would have agreed to such an arrangement. Lawyers aren’t told what they can charge clients. When the AMA traded what it thought was control of physician reimbursement for physician autonomy, the gradual slide of physician autonomy began.
Why did physicians tolerate this takeover of their practice by the Centers for Disease Control and Prevention (CDC)? If the loss of physician autonomy and integration we see today would have been introduced in the 1960s in one fell swoop, there would have been an outrage. But the slide into the loss of autonomy has been similar to the analogy of boiling the frog. The loss was gradual at first, imperceptible by many. But by 1996, the pharmaceutical companies had become so much a part of the big business usurpation of physician autonomy that the pharmaceutical companies lobbied Congress that doctors shouldn’t be allowed to own hospitals because they would overcharge for the care provided. Of course, no one seems to notice big business medicine and pharmaceutical compnaies overcharging the public. One very large step in bringing the cost of healthcare under control includes allowing physicians to own hospitals again.
In 2019, Uwe Reinhart, a well known economist, wrote about the high cost of healthcare in the U.S. in Priced Out: The Economic and Ethical Costs of American Health Care. He discusses:
“ why it costs so much more and delivers so much less than the systems of every other advanced country, why this situation is morally indefensible, and how we might improve it. (from Kindle description)
Elisabeth Rosenthal provides a particularly detailed history of how our healthcare system has become so controlled by big business in An American Sickness: How Healthcare Became Big Business and How You Can Take It Back.
In these troubled times, perhaps no institution has unraveled more quickly and more completely than American medicine. In only a few decades, the medical system has been overrun by organizations seeking to exploit for profit the trust that vulnerable and sick Americans place in their healthcare. Our politicians have proven themselves either unwilling or incapable of reining in the increasingly outrageous costs faced by patients, and market-based solutions only seem to funnel larger and larger sums of our money into the hands of corporations. (from Kindle description)
The best way to return integration to healthcare is to return the control of healthcare back to physicians and their patients. Doctors should own hospitals and the model of Direct Primary Care should be allowed to flourish.
The answers to removing fragmentation and reducing the cost of our U.S. healthcare system are out there, not only in these two books, but also in many other books about the high cost of healthcare in this country. To bring about needed change, Elisabeth Rosenthal says patients-consumers-voters must crusade to take back their healthcare by standing up against the interests of business and politics.