Published on
The Providence Journal

Insurance Hassles Killing Off Family Docs

John Brady

I love being a family physician. I love the history rooted in the country doc who did his best to help comfort and heal his neighbors. I love the broad scope of practice where I am always seeing something different and something challenging. But most of all, I love the long-term relationships with my patients. So it is with a heavy heart I admit that my specialty is dying.

This matters not because of the nostalgic loss of the way things were; it matters because studies have proved the essential foundation of a less expensive and higher quality health-care system is effective primary care.

Specifically, as primary care dies, access becomes limited, waits become longer and costs soar.

With this silent but looming crisis becoming ever more evident, we have to take an open and honest look at the reasons for the demise.

We are dying because of an insane payment system. Primary-care doctors mainly get paid for visits to the office, with each visit having its own particular insurance code. Although this sounds straightforward, every insurance company pays different amounts for different visit codes, and every patient has his own individual deductible and co-payment, so no one knows who owes what or what the final bill will be until the insurance company signs off weeks to months after the visit.

The process of getting paid is so complex it has spawned an entire industry dedicated to medical collections. But getting paid for visits also forces doctors to jump on the treadmill of seeing patients to fill their schedules.

Even one open slot is lost revenue, so patients who have something which could possibly be handled over the phone or through e-mail are forced to come in for a visit.

Schedules become packed and inflexible, leading to physicians who are harried and insufficiently empathetic and patients who are frustrated from hours wasted waiting for a five-minute appointment. The resulting chaos, due directly to the payment system, is unhealthy for everyone.

We are dying under the weight of useless administrative paperwork. To try to save money, insurance companies have begun to request prior authorizations on everything from medications to radiological procedures to seeing specialists.

This shifts additional administrative costs to the doctor's office, making the treadmill of patients run even faster.

But perhaps more insidious is that it makes doctors think twice before ordering a test or a consultation. After all, that is the only way these impediments can save money.

This creates a scary scenario where a necessary test may not be ordered simply due to the enormous hassle involved in getting it approved. Administrative trivia is not just annoying, it is potentially dangerous.

We are dying because reimbursement is not keeping up with costs. Payment for medical services is socialized, with most insurance companies basing their reimbursement on the Medicare fee schedule.

Since 2001, reimbursement has generally remained unchanged, even though the cost of practicing medicine has gone up 20 percent. If the Medicare Economic Index holds true, between 2001 and 2015 primary care will see an 81 percent net loss of revenue, making practicing medicine financially impossible.

Medical students are seeing this trend and are choosing the financial security of specialties that get paid three to 10 times more a year. Over the past 10 years, this has resulted in a 54 percent drop in the number of U.S. medical graduates entering family medicine - a patient's first step, and medicine's least expensive.

The current system pushes volume over quality and enhances short-term profits for insurance companies at the expense of the primary care office. These policies are killing primary care by eroding the doctor-patient relationship.

Recently, Family Practice Management journal stated that 60 percent of practicing family physicians would not choose the specialty again if they could go back in time. The main reason for their dissatisfaction is a lack of autonomy - a feeling of no longer being able to take care of patients without outside interference.

The tragedy is that in a time when we are searching for answers to our health care crisis, we are losing the one group who intrinsically understands the solution lies in the doctor-patient relationship. As that relationship withers and dies from outside abuse, so will primary care. Unfortunately, so will the health of our nation.


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John Brady, M.D., owns and operates an independent solo practice, The Village Doctor, in the Hilton Village section of Newport News, Va. He is an assistant professor at Eastern Virginia Medical School, a faculty member in the Ideal Medical Practices movement, president of HealthConnector, and was honored as the 2008 Virginia Family Physician of the Year. This piece originated in The Virginia Pilot.

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