Insurance, Practice, and Burnout Issues

There are a myriad ways in which insurance companies interfere and harass physicians in the ordinary course of the day. Some are direct and very obtrusive, some seemingly more benign. Pay for performance is one of those ways that at first seemed plausible, but in practice has proven very problematic. A recent article in the Annals of Internal Medicine has shown that pay for performance does not in fact improve quality or reduce cost. In fact, it makes matters worse because it penalizes doctors for the treatment of the sickest and most complex patients and then their “quality scores” suffer. The Medicare program that rewards and punishes hospitals based on arbitrary limit on readmissions for heart failure may have increased death rates. Recently, a Medicare Advisory Commission recommended that Congress repeal the Medicare pay-for-performance program initiated in 2015 by Congress as costly and ineffective.

Job Satisfaction

Then there is a decade of research that shows paying physicians by rewarding or punishing by quality measures, as most of them inaccurately measure quality, do not improve the health of patients. Furthermore, these programs harm the sicker and poorer patients. They create interruptions in patient care and reduce job satisfaction in physicians. There are cases of physicians avoiding sicker patients or avoiding more complex surgeries that have lower rates of success. Replacing physician judgment by insurance company oversight that watches the bottom line rather than the best interests of patients is demoralizing at best and dangerous for patients in its implementation.

Probably nothing is more aggravating or time consuming than pre-authorization. The degree of harassment varies between insurance plans, but in study after study, it is found that for the effort involved it actually costs insurance companies more to implement these policies than any savings realized. And that does not include the lost physician time, lost productivity, or cost of physician office staff labor. When that is all included, it is a huge waste of time and money. So why do these persist? It appears to be little more than harassment with the belief that it somehow cuts down on patient care and testing, lowing insurance costs. Multiple studies actually show no significant cost savings, and physicians and patients are directly harmed for no gain.

Costs of Practice

The costs of running a practice are enormous, and Medicare and insurance rules and regulations place an unfair burden. It is now untenable in many locations for new physicians to set up independent practices. The percentage of physicians employed in 2017 went over 50% nationally, much higher in certain urban areas. The unfair discrimination against private practice, such as paying far less for identical services if supplied by a private practice versus favored employed practices owned by hospitals, has placed undue strain on even long standing mature practices. In 2018 my own group of 14 cardiologists fell to the inevitable, and we are now owned by Partners Health Group led by Massachusetts General Hospital.

Is there little wonder why the dissatisfaction rate among practicing physicians rises every year? Why burnout is now so prevalent? Physicians have dedicated their lives to caring for patients, to the best of their abilities, only to be stymied, obstructed, and having to overcome nearly impossible hurdles placed in their path. When one is faced with impossible obstacles of which one has little to no control, yet expected to perform perfectly at all times, no wonder that burnout and dissatisfaction in career choice becomes so prevalent.

Articles:

  1. Physician Burnout, Harvard and Massachusetts Medical Society Study, January 2019:

http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/

2. Beckers article on Physician burnout:

https://www.healthaffairs.org/do/10.1377/hblog20170328.059397/full/

3. Prior authorization leads to physician burnout and patient frustration:

https://www.ama-assn.org/practice-management/sustainability/1-4-doctors-say-prior-authorization-has-led-serious-adverse

4. Athena insurance Co. profits by denying coverage in ER’s

https://www.stltoday.com/opinion/editorial/editorial-health-insurance-company-makes-big-profits-by-playing-hardball/article_265b6c91-75f7-5dbb-a8d2-6038e2cfffea.html

5. A Kaiser article of the frustrations of Electronic health records

https://khn.org/news/death-by-a-thousand-clicks/

Atul Gawande article on the frustrations of EHR, contributing to burnout

https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers