I recently attended an event honoring Dr. Katherine Upchurch, one of the attending rheumatologists I worked with during my fellowship at the University of Massachusetts. In her acceptance speech for the Massachusetts Arthritis Foundation chapter’s Dr. Marian Ropes Award, one thing that stood out for me was her acknowledgment of doctors who still practice “in this climate.” She did not elaborate on that, but my guess is that we all have a gnawing, if unenumerated, understanding that the practice of medicine today is quite different from even as recently as 20 years ago. I’ve witnessed some of the changes myself in the brief 6 years that I’ve been practicing.
Some changes have been tangible. For example, in 2011 the Centers for Medicare & Medicaid Services (CMS) started requiring the use of electronic health records that demonstrate so-called meaningful use. In 2013, the CMS started collecting information on quality of care by way of its Physician Quality Reporting System (PQRS). 2014 ushered in the new Maintenance of Certification requirements from the American Board of Internal Medicine, a change that has been contentious at best and onerous at worst. Most recently, Oct. 1, 2015, was the official rollout date for new ICD-10 coding, expanding our list of possible diagnoses to 68,000 (W61.1, contact with macaw, anyone?). 2015 is also the year that penalties start if a practice does not comply with meaningful use and PQRS. Every single one of these changes has made me feel like a child being told to comply “just because,” without the ability to question or argue.
Dr. Karmela K. Chan
There have also been more subtle changes over time that defy reduction to any specific date or agency. For instance, it was not too long ago that a doctor had more than 15 minutes for a follow-up visit. But Medicare reimbursement stagnated while inflation grew, so keeping practices open meant squeezing more and more patients in.
Meanwhile, insurance premiums and deductibles keep increasing. This imposes a burden on patients, often resulting in suboptimal care. Never mind that our patients can’t afford the biologics, they can’t even afford the copays required for physical therapy visits.
Contrary to the usual behavior of market forces, the higher cost of insurance does not seem to buy the patient more options. This further emphasizes that notwithstanding Justice Scalia, health care is not in fact just like broccoli. Instead, insurers are dictating which physicians, facilities, and pharmacies patients can use. They decide which medications and tests are covered based on algorithms, with little regard for the medical training that informs the physician’s recommendations.
These are just some of the changes that have made the practice of medicine so burdensome as to be intolerable to some. It is likely that these regulations have played at least some part in the unsustainability of small, independent practices, thereby reshaping the landscape quite dramatically. Already it feels like we are just cogs in the large wheel of corporate health care.
In China, children are actively discouraged from going to medical school because doctors are overworked and underpaid. Doctors are also often victims of violence perpetrated by disgruntled patients, probably because the overworked and underpaid doctors don’t have the means to care for their patients appropriately. I desperately hope this is not the direction our profession is headed in, because antagonism does not exactly become us.
Dr. Chan practices rheumatology in Pawtucket, R.I.