Systemizing Systematic Systems

Justin Coogle, M4, Class of 2019

The complicated reality of practicing medicine in today’s day and age

Health care is large and complex. Anyone who has spent one week working in a hospital, no matter the role, would agree to that.Even the layman who attends his annual physical exam or goes to see his doctor for a nasty cough obtains a glimpse of the complicated web we’ve found ourselves in when it comes to delivering care to the patient. Improving health care for our patients should be a universal passion, but health care reform isn’t so simple. If I were a betting man, I’d say no single piece of legislation or sweeping political campaign will fix the rut we’re in. Hot topics like “Should we switch to Single Payer?”, “Medicare for All!”, and “HMOs are the way of the future!” are all things buzzing on the news, because people are frustrated, which is totally fair. I’d like to share some issues that I think get overlooked in the national narrative and are the elements I personally find most disconcerting when it comes to the future of health care reform.

But before diving into that, here’s some background on me. I’m a graduating 4th year medical student who will soon be starting a child neurology residency at Children’s Mercy Hospital here in Kansas City. This was my dream residency and I am very happy to have been selected for it. However, if you knew me as a 2nd year medical student, a 1st year, or Lord forbid when I was a pre-medical undergraduate, you would have laughed at the thought of me reaching such a goal. I knew very little, and I mean miniscule, tiny, microscopic little, about health care systems (let alone American health care) when I was accepted into medical school. I was privileged with a father on military medical insurance, so everything came at practically no cost. An ED visit was $30 and I essentially treated it as my primary care in my youth. I knew nothing about the complicated bureaucratic web and games played between facilities, insurance, and providers. They were hard truths to swallow when I began to acquire an understanding in my 3rd year of medical school.

Culture Matters

There are many reasons why the system feels bloated. One reason is culture. More specifically our individualistic culture, and (one we maybe meme too often) the lawsuit-happy culture America prides itself on. This was most palpable during my month-long rotation down in the Emergency Department. There is an ever-present “lawsuit” boogeyman lingering over the shoulders of every emergency provider. They dish out shotgun orders of tests and imaging studies on almost every patient that comes through the doors. “Well, if they leave, and something were to happen, I’d be liable because they came to my ED and I chose not to explore every option even if the chance of them having X was statistically low.” This type of care is known as CYA or Cover Your Ass. I mean sure, some of this is to be expected, but it shocked me when an attending physician informed me on Internal Medicine that “25% of all hospital expenditures are spent purely on administrative, legal, and insurance negotiating tasks”. That is a quarter of hospital funds not being used for patient care (yes, it’s technically connected, but you know what I mean). Now imagine how that number will only rise as hospitals grow (much like our own KU), staff sizes increase, and a growing “gotcha” culture continues to expand.

What else does a system bloated by legal mumbo jumbo mean? Bureaucracy. And lots of it. We have to write notes. We have to write notes about writing notes. We write notes with such detail that it would make Tolkien jealous. Notes describing things you likely didn’t check (Did you really do that full Review of Systems and Physical Exam on every patient that day? Yeah, okay, you liar). The clerical tasks begin to outweigh the medical ones. The paperwork and electronic button clicking stacks up into an overbearing pile at the end of the day. Oh, and if you’re the primary team or a primary care physician, you bet you’ll be making all those phone calls to all the specialists, coordinating every little thing that needs to get done before 5pm, because it’s right for your patient. It builds, and then it discourages, and then it suffocates.

All of this adds to our system feeling bloated, slow, and unsatisfactory. How can legislation fix this? How do we dig ourselves out of this now very cultural (hospital and mainstream culture) hole we’ve found ourselves in? I’m not sure.

Physician Compensation

Now let’s take a look at the way physicians get compensated and how that affects a hospital’s priorities, and by conjunction the nation’s health system in general. Physicians are usually compensated on a combination of salary plus RVUs (relative value units). RVUs are, in their most basic form, the amount of work or tasks necessary to treat a patient at any given time. For example: if you order a CBC, CMP, TSH, and UA in addition to performing a physical exam at a scheduled appointment, you can charge for each of those separately. Now you have to compare the value of different RVUs. If you had to guess the cost between an open laparotomy for bowel perforation clean out versus ordering a few labs, which do you think would be the higher RVU? It is not uncommon knowledge that most procedures (surgeries being the most complicated procedures) net larger returns. This also explains the most lucrative specialties, they are largely procedural (Neurosurgeons, Orthopedic Surgeons, and Dermatologists do a lot of procedures in case you didn’t know).

That whole algorithm is already kind of complicated (especially when you realize the exact value of RVUs is more a spectrum than a hard number, and how people interpret those RVUs and translate them into actual compensation can change with employers), but to thicken the plot further we need to discuss transparency.

Price Transparency – or Lack Thereof

If you asked a patient how much their visit to the Emergency Department would cost, you’d probably just hear “A lot” or “Way too much” or maybe “Thousands of dollars”. And none of those are necessarily untrue. However, if you ask the ED nurses, residents, physicians, or other auxiliary staff you’d probably get very similar answers. There is a general yet non-specific understanding of the relative cost of certain items and services. Through my 3rd year of medical school I had many doctors throwing out quotes for various studies. “An abdominal CT scan costs $1,400”, “A 2-view Chest X-ray only costs $50!” or my personal favorite since I’m going into child neurology “Think real hard if your patient needs an MRI, those cost about $5000”. Maybe that CBC costs $10. Maybe it’s $100. Who knows, but your patient still needs it, so you order it and hope the magical insurance company covers it. This train of thought isn’t too uncommon, especially when a doctor had a chaotic day.

You hear these numbers and you may be thinking (both as provider and patient) “Wow, that is a lot of money. Where is that price coming from?”. That’s a fair question and it sadly introduces us to our next issue that further turns our health care stew into quite the dinner debacle.

The numbers, in all honesty, are pretty arbitrary and vary from facility to facility. What KU Medical Center charges for a CBC (complete blood count) is different than what Truman Medical Center or Overland Park Regional charge, which are all likely much higher than what Medicare charges (since Medicare’s costs are traditionally the foundation for where these prices start). How do they decide what to charge? From what some of my attending physicians have told me, “With whatever they can get away with and that can help keep the hospital out of the red.” Now at first glance that seems predatory, but it saved KU Medical Center from a state of decay.

Prior to 1998 KU Medical Center was owned by the state and was in a rather poor state, running deep in the red and sporting dilapidated facilities. In 1998 KUMC went private, no longer received state funding, and became a separate entity from the medical school. Since 1998 KUMC has exploded into the impressive and growing facility it is today. However, that was built on such pricing models behind these transparency veils. The Trump administration recently initiated a new policy that all hospitals were forced to post their list prices online. However, most hospitals simply post chargemaster lists, giant compendiums of prices littered with abbreviations and no context that sort of spoil the whole point of the policy. This kind of sucks and makes nothing easier. I’m not quite sure how we as evidenced-based physicians found ourselves in a system with no standardized pricing.

The Physician ‘Good Life’

Next, I’d like to touch on the expected lifestyle and “payout” of a physician. There is a prime reason why international grads fight to the teeth to get trained and acquire a job here in the states — the pay. This is no secret; American physicians get compensated leaps and bounds higher than almost any other equivalent physician globally. A constellation of things contributes to this: the low amount of residency spots (which then heightens the value for specialists because there is a very finite amount that hospitals have to fight each other for), the commercialized element of our health care, and the cultural respect the physician role still holds. I’m sure there are others, but those are the ones I most often consider. A change in health care will likely mean a change in compensation. If patients are better for it, I would wager that most American physicians would be more than agreeable to a reasonable pay cut, but that’s a more philosophical argument. The other flip side of the coin is the exorbitant cost of undergraduate college and medical school education. With all that debt students expect to earn the money to pay it off. After having just finished my 4 years, I’m honestly not sure why schooling is as expensive as it is, but that’s a soapbox for another day.

No Easy Fix

And finally, I just want to comment on the war on ignorance. The more you learn about medicine, health care, and how everything works, the more frustrated you get at political pundits or click-bait articles that feed on the very real ignorance of the mass populace. An average Joe likely does not know how his 10 medications work, nor should he have to; that’s not his job, that’s our job. A patient should be able to have faith in their health care providers, and for a time maybe they did. But now we’re competing with enticing articles, closed internet communities (looking at you anti-vaxxers), corrupt physicians or “doctors of alternative therapies,” and equally ignorant celebrities or political figures whose words carry far more cultural impact than our own.

The amount of misinformation, both external and internal (Yep, we’re at fault too. Ever had a patient get conflicting information from their surgeon and their primary care physician? It happens.) is daunting. The price of freedom of speech. How exactly is a policy change or a piece of legislation going to fix a question that speaks to the core of our civil liberties? I don’t know the answer.

A Look Forward

If you made it to the end of this piece, then I applaud you. Really, I do. Because reading about this, hearing about all these issues, it’s exhausting. Systems suck, they’re suffocating, and I didn’t even offer any answers because I don’t have any. But don’t be discouraged. I’m not. America today isn’t perfect, far from it, but I’d rather be living here right now than anywhere else at any other time. And when I look at my graduating class, all the future physicians of varying specialties, I calm down. Even if it’s one physician at a time (and that is where I suggest you start one patient, one physician at a time) we’ll get better at this whole health care thing. Politics is frustrating and often disenfranchising. A lot of our life can be. But that moment when you’re talking to your patient and performing the ancient ritual of the physical exam? That is real, that changes lives. It is truly a blessing, a privilege, and a great honor to do what we get to do.

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