We are still waiting for the details of the Obama care bill that is going to save American health care, whether we want it or not.

One is reminded of the saying: The devil is in the details; and indeed, in these days when money is going to rule all of us, one has to wax nostalgic for days when patient care, not paperwork, was the most important part of a physician’s day.

In the “good old days”, you went to the family doc, who lived in the neighborhood and had his office in an ordinary home. You waited in line if you had to be seen right away in the morning or after five, or had an afternoon appointment.

He (and in those days it was rarely a “she”) saw you,  talked to you about your mom and family while he treated your cold/bad heart/warts. You then gave his nurse $2 to $5 dollars, and left.

Even when I was first in medicine in the early 1970’s, it was the same. I could keep up the office for ten dollars an appointment, twenty for a pap smear or longer visit.

But if I wanted to see Medicaid patients, if I charged $10, I was reimbursed  $7, and lost money. So I had to raise my appointment fee to $17, so I could be reimbursed for $10. That hurt the local farmers, who usually only had insurance to cover hospital expenses. I started to charge a lower fee for “cash” but then the government told us this was “Medicare fraud”, so that had to stop.

What we ended up doing, of course, was seeing four farmer’s kids who were sick and only charging for one or two, so there was no paper trail, or charging a short visit for a longer one for those who paid cash. Luckily, the government didn’t catch on.

Fast forward twenty years.

Now everyone had insurance, so everyone, even those who had a high deductible and paid cash, had to be billed. Some of our patients would simply keep the bills toward their deductible, or could send in the billing themselves, but for the elderly this meant a lot more paper work, so I had to hire a second secretary just to do billing.

Then there were the “multiple billings”, when a person had insurance and Medicare, or two insurances (e.g. car accident). Often the insurance companies would argue, so since a lot of our patient couldn’t pay us, it meant we sat on the large bills. We had to bill every month to keep the bill active, however, resulting in upset folks, who we instructed to either pay ten dollars a month to stop the automatic “you will be sent to collection” warning, or remind the secretary to tag the bill.

Then there was the “You filled the number out incorrectly” or other “Games bureaucrats play to delay or prevent paying patient billing”.

And, of course, the patients were different. Pap smears and other screening tests needed to be done, more immunizations for kids and adults, with constantly changing rules, and more importantly, people with high blood pressure no longer died: They just needed to be kept an eye on to make sure they didn’t think they no longer needed the medicine. And heart patients? Now they didn’t die: They had their bypass, and saw the cardiologist, so we had to coordinate our care with the specialist.

We now have more specialists. Originally, a referral meant a short note or phone call to the specialist, but now, in some HMO’s or in the Federal system, this meant paper work for the referral, both to insure they got their bills paid for, and for the lab and xray data and medicines already tried: Information that was too much for grandmom to remember.

Then came the privacy act, which meant more paper work to release their records, or else face a huge fine if it wasn’t done right.

So will the Obamacare make things easier?

I worry. The complicated insurances things are still there. And now we will have more paper work, or maybe even check lists on our IPads to prove we checked all the unimportant things of a person who came in for a diabetic check if I wanted to get paid. (yes, I checked her face, but her acne rosacea wasn’t important this visit, so why do I have to note that it was examined?).

The problem with modern medicine is that it is now a business. The bean counter wants everything in black and white so you can be paid, and with the government push to increase efficiency.

This means that they, not you, will decide how long you will spend with your patient. Ten minutes to treat a “cold” is enough, never mind that five of those minutes is spent filling out forms.

So a lot of time is spent collecting unimportant data and using our time “efficiently”, meaning an increased chance of not finding or caring for what is really important (stuff like if the kid with the cold is now sexually active and needs birth control, or having the time to talk with grandmom and discovering that the reason she isn’t eating properly because her druggie son stole her pension check again).

Years ago, I visited a colleague in Canada, and saw his billing sheet.

One sheet for billing ten patients: one patient per line.

Patient name, number, diagnosis, office charge.

That was it.

I was aghast. Don’t know if it still is that way, but damn, it would save a lot of money if it was. Sure some docs would cheat, but they cheat anyway.

That is why I tend to agree with the Nation: ditch the complicated Obamacare bill and go for a single payer system.

But only if the paperwork was simple.

Wonder why they charged you ten dollars for a simple tylenol in the hospital? Pill costs  5cents, but the pharmacist, the daily inventory, and the paperwork so they can charge for the pill costs $9.95…

What needs to be done is to get a level of trust in there, one that figures not everyone is out for a buck. And private enterprise, with it’s business approach to medical care, is not the answer.

As the Nation notes:

…the president is equating career civil servants – like the folks who organize the military’s health care, services for veterans, the existing Medicare and Medicaid programs, the Indian Health Services and the care provided for the president and his family – with insurance company profiteers who refuse coverage to people with preexisting conditions, discriminate against women and the elderly in establishing pricing structures and connive to deny care to Americans when they need it most.

Only one set of paperwork, and one set of bureaucrats for doctors to fight, instead of a multitude of different programs with different billing and different criteria and different faceless decision-makers to fight…

But having worked for the federal government for ten plus years, I’m not as optimistic as they are about fighting the bureaucrats.

Go to your local VA Hospital or Indian Health Service Hospital before you decide.

You’ll see good basic care given in an unattractive clinic, with more people in the nearby offices than in the clinic. The hospitals will be good for basic care, but if someone quits, it takes months to refill their job, since you only can start recruiting for that job until after they leave. As for equipment: first you apply for it, then you get it approved, and then you wait for it, and wait, and wait, while the contract is put out for bids, and then the bid is decided, and maybe even more wait since it won’t be paid for until next year’s budget.

Reality check:Both systems posit something more important than the patient: Insurance companies the cost, and “civil servants”, the regulations. And boy, are those regulations followed.

No, I don’t have an answer, which is why I took early retirement.


Nancy Reyes is a retired physician living in the rural Philippines. She blogs at HeyDoc Xanga Blog.

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