The American healthcare system is complicated. I often wonder if I am complicit in its abuses because I am a doctor. 

I get a paycheck every 2 weeks for my services to patients that are part of the hospital system that is my employer. I do not get paid more to write more prescriptions, refer patients to other doctors, or order more labs/tests. I get paid for how I code the patient’s visit. The more complicated the patient or visit, the higher the code and the bigger the charge. In complete transparency, I have no idea how this gets calculated. I have no idea if I am being short changed by my employer. In some ways, I prefer to be ignorant, I NEVER want to be aware that if I code X I get paid Y. It might change the way I practice. I might be inclined to fudge the charges just to make more money.

It gets complicated because I work for a hospital system that gets paid from the insurance company by how I charge. The insurance company also dictates how I practice by limiting my ability to order tests/labs, medications, or make referrals because of the cost to the insurance company. They can deny my tests, referrals, and medications. When they deny my orders, the patient would have to pay for this themself or not get the care they need. 

I have made phone calls over the years to battle the denials. Sometimes I am successful, sometimes I am not. My office employs a full time position to battle medication denials. I can think of many people over the years that had delays in care that directly impacted their outcomes. I have also changed my practices over the years knowing what will be denied. For instance, if a patient has back pain, the typical scenario is: 1. Try meds first 2. If not better get an X-ray 3. If not better, refer to PT 4. Try to get an MRI but if denied send them to Ortho/Neuro. I have to do this EVEN if I know getting an MRI first is the right step. This delays care, delays diagnosis, and delays healing.

In one of my jobs, my role placed me in a position to meet with CMOs (Chief Medical Officers) of insurance companies every quarter.  Because I am a little mouthy, when I first met  them, I said, you know you work for the enemy now. I actually felt sorry for them. In their positions they no longer work with patients. Their goal is to decrease medical spend which seems reasonable on the surface. Medical spend is out of control. However, by tying to decrease medical spend, they are actually withholding care. Or they are creating convoluted algorithms  (like the back pain scenario) for providers to follow to slow the care provided hoping the patient and provider just gives up. 

These were decent people who once took an oath to do no harm. Some of them felt they were fighting the good fight from within the insurance company. And I believe that they where. It’s a losing battle unfortunately because profits, bottom lines, and savings are the ultimate goal, NOT patient care or health outcomes. 

How am I complicit? It’s hard to keep fighting. I get tired. Who has time to make all these calls? Who has time to keep following up and pushing back against each company for each patient? I have changed my practices. When I study for my boards, I have to remember there are 2 different ways to practice medicine. There’s the right way when you order the right test for the right complaint and then there is the wrong way. The wrong way follows the money. The wrong way limits healthcare access and timeliness of care. The wrong way hurts people and prolongs their pain.