There are so many problems with the structure of the health care system in America that it sometimes seems really challenging to figure out how to confront them. All of these pieces fit together, but they can’t be taken on all at once, because that way lies disaster. So it is that we must take them in bibs and bobs, with the understanding that they all interlock — and none of these problems are simple, or solvable in a single brief op-ed.
I’ve been thinking a great deal lately about the role of bureaucracy in the lives of medical providers. The practice of medicine has never been just about seeing patients and providing treatment — unobserved (by the public) are things like updating charts, coordinating with other care providers, pursuing continuing education. Physicians in a practice may have staff who handle things like scheduling, medical billing, supply orders, and the like, but that by no means suggests that they’re exempt when it comes to dealing with bureaucratic issues.
I was struck by this in an appointment recently with a care provider who asked not just about post-surgical support, which is a reasonable question to ask, but also some of the bureaucratic issues surrounding surgery. He wanted to know about my level of health insurance and whether it would cover the procedure, because it’s a concern for many of his patients and he didn’t want me to be caught up surprised. Somehow, dealing with questions of cost and affordability had become part of his job.
Doctors have been having financial conversations with patients for a very long time, especially if they work in low-income communities. The optimal treatment isn’t always the one the patient can afford, so they have to think carefully about that. Back in the days of glorious amounts of pharmaceutical samples, sometimes doctors would ease the burden with freebies to help patients stretch their resources. Sometimes it’s about structuring charts in complicated ways, or searching for justifications, to ensure that procedures will be covered by insurance. Doctors become adroit at administration because they want to care for their patients.
This shouldn’t have to be a part of medical practice. We should live in a world where physicians can focus on patient care and neither party has to stress out about questions of whether insurance will cover something, whether they can afford a costly long-term medication, how they’re going to deal with administrative stresses. Where conversations about the correct course of treatment can focus on questions like effectiveness, desired outcome, quality of life concerns, rather than which treatment is within financial reach.
Being a doctor, according to my generalised understanding, requires a tremendously complex set of ever-evolving skills and experience. Medical practice is very hard work, and that’s a lot to be getting on with as it is before you start adding on administrative duties. I think most physicians would rather not be dealing with administration — can I prescribe this or will the insurance kick it back to me, can this patient afford the copay for this, how do I justify this medically necessary procedure in a way that will pass muster — because it’s a distraction from their work, and it’s annoying, and they have better things to be doing. I’d argue that it also cuts into their quality of care both by splitting focus and forcing them to run a constant calculus of compromise in interactions with patients.
For me, this is another piece of evidence that universal single payer would make our lives a lot easier, but also a lot healthier. I’m well aware that universal single payer comes with its own bureaucracy, including issues like refusing to pay for certain procedures and creating other snarls for patients. I’d be interested to hear from physicians working in single payer settings, though, about the kind of bureaucratic work they do, how much time it eats, and whether they think it interferes with their jobs.
The cost of running a health care bureaucracy is definitely a component of discussions about single payer, but often it focuses on things like how expensive and frustrating it is to process a gajillion kinds of insurance, how inefficient it is to basically replicate the same organisational structure across multiple government-administered health plans and private insurance companies, how arcane medical billing requirements are a nightmare for medical practices and hospitals. But what about the toll it takes on doctors, who maybe would prefer to be doing something that is not this? Who could spend more time with patients if they weren’t constantly chasing down weird administrative problems and trying to resolve them?
We think of all of this as reasonable and normal because it’s all we know, and it’s become a hindrance to trying something different. Sure, doctors once dealt extensively with bureaucratic issues because single doctor/receptionist practices were a thing that could functionally exist, and the administration of medicine was much simpler, cleaner, and easier to manage. But this isn’t 1880, or 1940, and we can do better now.
Image: Doctor Examines Infant, World Bank Photo Collection, Flickr