The first in a series of articles about the challenges of practicing medicine
One of the functions of this magazine’s Physician Advisory Board is to recommend medical topics and others areas of interest that Hampton Roads Physician should cover. Dr. Jon Adleberg suggested that we take a look at the ever-increasing level of dissatisfaction among practicing physicians, and the toll it might well take on healthcare in America.
We started doing some research, and were frankly surprised at the amount of reports and surveys readily available by doing a simple Google search – and equally dismayed by the statistics we found.
Five years ago, for example, a survey conducted by The Physicians Foundation found that 40 percent of doctors planned to drop out of patient care in the ensuing one to three years, either by retiring or seeking a nonclinical job. A 2012 survey conducted by Medscape/Web M.D. showed dissatisfaction among US doctors rising: an online questionnaire of 24,000 doctors representing 25 specialties reported that only 54 percent said they would choose medicine again as a career, down from 69 percent the year before.
In 2013, acting upon a request from the American Medical Association, the nonprofit research organization RAND compiled a 150-page report entitled Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Among other reasons for professional dissatisfaction, the report concluded, was a common theme that physicians feel stressed when they see barriers preventing them from providing quality care.
And the 2014 Deloitte Annual Survey of US Physicians reiterated its 2013 finding that most doctors remain concerned about the future of the healthcare profession.
We wanted to find out if the experience of physicians in Hampton Roads mirrors those reported in these national surveys, so we reached out – first to the members of our own Advisory Board, and then to some of the physicians and practices we’ve profiled over the last two years.
We began with Dr. Adleberg, an ophthalmologist and retina specialist in private practice with nearly 20 years experience treating patients with severe vision problems. He’s often required to administer intraocular injections when other modalities like drops and pills cannot treat the retina effectively. This is especially true in the case of wet macular degeneration, a chronic eye disease that’s generally caused by abnormal blood vessels leaking fluid (or blood) into the region of the macula. Left untreated, it can cause permanent vision loss. “We doctors have to purchase these medications and then apply to the insurance company for reimbursement,” he says.
A recent problem arose when, despite going through the pre-authorization process and obtaining approval for such an injection – and receiving reimbursement – Dr. Adleberg received a letter from the carrier two months later, demanding that he return the $4,000 payment. The letter further advised that should he decline to do so, the money would be deducted from any future claims he submitted. His office staff, after several calls to the carrier to ascertain the reason for the denial, subsequently resubmitted the claim per their recommendation. It was rejected, again with no reason given.
That’s when Dr. Adleberg got involved. He tried emailing and calling to no avail, and ultimately asked his Congressman to intervene. The claim was finally paid – but only after he’d spent 30 hours negotiating a frustrating bureaucratic labyrinth. “The carrier told us one thing, but failed to communicate that to their software. I felt that the insurance company didn’t care two hoots about the claim, about me or about my patient,” he says. “And honestly, if I weren’t a solo practice, and it wasn’t such a large amount, I probably wouldn’t have bothered – but it was just too much.”
In Dr. Adleberg’s case, it wasn’t a question of him or his patient not understanding the limitations of coverage, but that is often the source of much frustration on the part of both doctor and patient, says Dr. Jeffrey Carlson, an orthopaedic surgeon who joined Orthopaedic and Spine Center in 1999. “Our frustration as doctors is that patients too often get their information about healthcare coverage from a media article or something they see on television, rather than taking the time to investigate what they’re really getting from their specific policy,” he says. “Insurance is complex, and all policies are not equal.” He’s had patients who both need and want an MRI, and had to tell them that their insurance won’t cover an MRI. “We have to go through this algorithm of how to get an MRI: the patients have to go through physical therapy; they’ve got to get a shot; I’ve got to give them medication,” Dr. Carlson explains, “and then in three months, after all of that fails, then I can order the MRI that I knew they needed when they first presented.”
Dr. Margaret Gaglione, an internal medicine physician in private practice, shares her colleagues’ frustrations. Her office accepts 14 different major insurances, including Medicare and Medicaid. “There are so many different requirements, and each company pays for something different,” she says. “One pays for one drug, but not another. Patients may have a very high deductible – or even if they have a specific carrier, they may have a subset of that insurance that doesn’t cover a drug I want them on.” An example would be some of the newer diabetes drugs (incretins and glucosurics), which are physiologically so much better treatments because they don’t cause weight gain, but they are of limited value to patients who have chosen very high deductible plans, or are on Medicare.)
For every one of these doctors, dealing with claims that have been denied has become a standard part of every day in the office. “Every minute doctors spend on the phone, navigating paperwork, meeting all these different requirements that no one could possibly keep track of – that’s all time we’re not able to spend with patients,” Dr. Gaglione says. And of course, it’s all time for which physicians aren’t being paid.
It’s not just the established physicians with years of practice behind them who are experiencing frustrations. Dr. Paa-Kofi Obeng, with Bon Secours Nansemond-Suffolk Family Practice, has been in practice a little more than a year. “I think the shock has been more the red tape you have to go through when treating a patient,” he says. “You’re sort of shielded from that as a resident; you don’t have to deal with it.” He’s experienced similar problems attempting to get his patients the medications they need, when they need it. “More medications are being denied based on insurance guidelines, even though I know a particular medication is better for my patient,” he says. “You feel like your being dictated to by an insurance company. They don’t want to pay for the medication you prescribe; they want you to try another (cheaper) one, even though you know what they’re suggesting isn’t going to be effective for the patient.” In a particular denial he’s fighting, Dr. Obeng notes, the medication dictated by the carrier would have harmed his patient.
There’s no class in medical school or fellowship that prepares physicians for the volume of administrative red tape that goes hand in hand with the practice of medicine, unfortunately. “I think they’re trying to address that in medical education now,” Dr. Obeng says, “but there wasn’t for my class.”
Whether or not such classes are introduced, each of these four physicians we spoke to said they went to medical school to learn the specific knowledge and acquired the technical prowess and medical expertise they would need to care for the patients who come to them for healing and cure.
It is their belief, expressed by Dr. Carlson, that the best treatment plan is made by the doctor who is actually treating the patient. <
