I have been practicing internal medicine for 24 years and have seen a lot of change. I started after HMOs were already around, so I was not in medical practice when a physician billed a patient and the insurance company sent a check for that amount (or a portion of it). HMOs were conceived when a group of doctors told insurance companies that they would see patients for a reduced rate in return for higher patient volume. That resulted in a global system of reduced fees for services compared with the past. This caused physicians to have to see more patients to make the same amount of money they were making before. They might need to rush during office visits, potentially affecting the quality of care the patients received. We can see how these events have affected the doctor-patient relationship. Patients have been angry at being rushed, doctors have resented getting paid less for the same work, having to work harder and also increasing the risk of missing something important during the visit. It gets worse from there. The reimbursements doctors receive have been decreasing year after year and at some point they consider that it may not be worth seeing patients with certain health insurance plans because of how little they get paid.
As HMOs became the norm, large medical practice corporations sprang up and promised doctors higher reimbursements because of increased negotiating leverage against the health insurance companies. As a result, private practices for internists basically disappeared because they simply could not make ends meet with the low reimbursements they were receiving. Physicians became employees and ceased to be independent business owners. On top of that, the insurance companies and pharmacies now have more power over the patients’ health than the physicians. I prescribe a certain medication for a patient and then learn that it is denied by the insurance company; I am then forced to find an alternative, which the insurance does cover, but may not be as effective as what I’d prescribed initially. Also, pharmacies tell patients that they do not have a medicine in stock and instruct the physician to prescribe something that is in stock. All of this increases the amount of time physicians spend on paperwork when that time could be spent taking care of patients. I may spend up to 40% of my day dealing with these issues instead of taking care of patients.
We now also have a new threat to our practices: urgent care centers. These are facilities that see patients without appointments, accept most, if not all, insurance, and don’t care if their customers have private internists. They take advantage of the public’s desire for immediate medical attention; someone can just walk in to their offices instead of needing to wait for an appointment. I work six days a week, starting at 7:00 a.m. every day. Nevertheless, I have been told by my patients that I am “inconvenient.” There seems to be no loyalty from patients anymore—they feel that instant satisfaction is more important than having a doctor with whom they have built a relationship over years. Even if patients want to see me, there is another huge roadblock—their own health insurance. Most plans have huge deductibles in addition to the high premiums, so patients who are now forced to buy health insurance cannot afford to use it because nothing will be covered until they meet their potential five-figure deductibles. So, patients will be inclined to not use their insurance and then wait until they have an emergency for which they must go to an emergency room for more serious care than they would have needed had they gone to their physician when their problem first began. All that does is increase the cost of health care.
How can physicians “compete” against all of these issues?