copyright © 2008 Betsy L. Angert. BeThink.org
Twas the night before Election Day and my mind, heart, body, and soul were filled with fright. I fear I did not do enough; nor could I have, to truly bring about change. I more needed time with those that trust me or were still open to reflection. When last I made calls for candidate Barack Obama, I was slammed, damned, and spoken to with much disdain. Similar occurred when I stood on a street corner and waved my signs. Granted, I saw and heard there was much support. Still, I had friends who would not vote for Senator Obama. Several were sure that they preferred John McCain and Sarah Palin. Then, there was John Michael Rubens. John is eligible, older; he is registered. This fine fellow has cast many a ballot in his lifetime. Doctor Rubens is prominent pillar of the community. The well-trained physician is a scholar. He cares. Yet, he would not cast a ballot for either candidate.
John’s positions affected my faith. Everywhere I went, other people told me to believe, to be hopeful. However, I knew that no matter who entered the Oval Office, blood would be spilled. On battlefields abroad and on the streets of America, brutality born of terror would continue to flow. For some people weapons wield strength. Innumerable individuals use words to kill. Some take advantage of signatures on insurance forms, benefits no longer offered with salaries, or just the Health Care system.
Hours before Americans went to the polls, my very close friend, a man familiar with the field of Health Care and the coverage necessary to treat illness and injury, spoke of what time, or a national election tally would not easily erase. Doctor Rubens avowed, the tangible that he thinks is in need of serious attention, is the way in which medicine is taught, practiced, and paid for.
John believes the Health Care system is a mess. He fears it is too far-gone. No Doctor, Democrat, or Republican, can revive a lifeless body that is virtually dead. Doctor Rubens offers his diagnosis; the institution known as medicine is virtually dead.
Doctor Rubens has long felt antipathy for elections. For years, I have endeavored to persuade him to vote. I did not have, nor did I express, disdain for his decision not to cast a ballot. I only hoped life’s daily doings would encourage him to go to the polls. As he shared his personal narrative, I inquired. “Will you vote in hopes that coverage, costs, and the circumstances for practitioners and patients are improved?” “No,” was the immediate response.
He laughed. John Rubens was not joyous or jovial. The physician was pensive. He pondered aloud. No amount of money, and neither of the Presidential candidate’s plans will do anything to improve what John just experienced. John Michael Rubens recently returned from an extended hospital visit. He was the patient, not the physician.
While in the hospital, it became increasingly obvious to the man I love, hospital staffs are underpaid. Personnel are scant. Each day more and more positions are cut. The economic downturn has had a direct effect on employee benefits, on whether ill or injured persons seek care, and on the ratio of attendants to individuals admitted to the hospital.
J.M. Rubens, M.D. observed nurses, physical therapists, and specialists in surgical procedures are asked to stretch them selves beyond what any person could physically, or emotionally endure. He recounts his own medical history, as a Doctor, and in treatment. John marvels. Surgeons, who may stand for as long as seven hours in the course of a single operation such as his, make less per hour than he earned decades earlier. The number of people medical practitioners in every field serve has increased.
Among specialists, invasive cardiologists’ compensation declined (0.18 percent loss) even before inflation. Conversely, noninvasive cardiologists’ compensation increased 11.72 percent. Compensation for emergency medicine physicians and hematology/oncology also failed to keep up with inflation. Specialists who fared better included anesthesiologists (6.43 percent increase above inflation) and urologists, posting a gain of 5.5 percent above inflation – compounding a similar gain in 2006.
“Although primary care physicians posted modest gains in compensation as a result of increased productivity and re-weighting of evaluation and management codes, overall practice costs continue to rise at staggering rates,” said William F. Jessee, MD, FACMPE, president and CEO, MGMA. “The continued uncertainty of the reimbursement environment creates an untenable situation for physician groups.”
Compensation, when it comes, is inadequate. In truth, the doubtful delivery of reparation is, in part, why John retired early. If the patient is “covered” by Medicare, reimbursement is less. The time needed to evaluate is not considered in the repayment. Little is.
Doctors have complained for years that Medicare rates haven’t kept pace with costs, such as new technology and the added paperwork required by insurance companies. The formula for determining reimbursement rates has basically been unchanged since Medicare was created in the 1960s, said Gondo.
Medicare reimburses doctors for about 46 percent of their fees while private insurance pays from 60 to 65 percent, said Dr. Timothy Melhorn, medical director at Cornerstone Medical Clinic, which is owned by Yakima Valley Memorial Hospital.
Medical practices incurred a 7 percent increase in operating costs in 2005, but Medicare reimbursed doctors less than half that amount, according to the Medical Group Management Association, which advocates for medical practice managers.
Doctor Rubens reminds me of what he received when I was a Medicare patient. The payment was very low by today’s standards. Even then, before he saw me, he told me he would not take on another patient who did not have private insurance. His office maintained a waiting list. Quality referrals were my entrance into his office for one visit. All those decades ago, John agreed to see me for a single appointment. Fortunately, for me, during our first encounter, he realized we had so much in common. John Michael Rubens, thankfully, decided to add me to his workload. Rarely, do the millions on Medicare list have this opportunity.
Today, in territories such as Texas, more than forty percent [40%] of physicians will not accept new Medicare patients. Before 1990, ninety percent [90%] of medical professionals were willing to take on the persons now turned away.
At the time, Doctor Rubens saw me, he felt he could afford one more “charity” case. Today, he observes medical professionals do not have the time to be so benevolent. They work more hours than is healthy. Money does not motivate them. Indeed, the profession is no longer a fruitful pursuit.
The physical condition of the health care system is not what it was a score ago when John saw me as a patient. On many occasions, Doctor Rubens has said, “Physicians’ income fell 7 percent between 1995 and 2003 after adjustments for inflation.” I have heard the many stories. I recall what he shared of his last years in practice.
When John Michael Rubens was eight years out of Medical School, he was able to purchase a house in an exclusive enclave. That property is now worth millions. The lot looks over the Pacific Ocean. From what was once his window years ago, he had a panoramic, breathtaking view of the surf and shore. Today’s Doctors, John declared with a deep sense of distress, even after many years in practice, cannot begin to pay for what he had after less than a decade.
In 2006, in what feels like an eternity ago when we consider today’s economic crisis, the greater number of jobs lost, and a reduction in employer provided benefits, it was reported that Doctors’ income falls over eight years. Primary care physicians are impacted more than specialists; although at the time of this survey, surgical specialists’ revenue dropped 8.2%. Young persons who, in the past, thought a future in medicine would be wondrous, are affected by reduced returns on an ample investment. Fewer wish to enter the medical profession.
Earnings are but one consideration. Malpractice premiums, technology for an office and personnel are large expenses. Then, there is the paperwork, and telephone calls not paid for.
“Every day, I spend at least an hour after my workday to call patients back, to discuss lab results, to discuss test results,” Ryan Mire said. “That’s not compensated.” . . .
“Just in the last three weeks, I have actually noticed three medication errors from specialists who prescribed medications for my patients because they did not have the full history,” Mire said. “I received those consultation notes, saw what the specialist prescribed, and said, ‘Absolutely not, do not take that medicine.'”
Yul Ejnes, a Rhode Island internist also on the panel [part of an internal medicine conference in DC] added a couple other typical primary care tasks that aren’t reimbursable: “talking with family members,” and “just sitting down and thinking” about a case.
“Sometimes I wonder whether I want to keep doing this,” Ejnes said.
These doctors are not alone. John Michael Rubens wrestled with the question for quite some time before he decided emotionally, physically, economically, the career he once loved was not worth the toll it took on his personal and professional life.
Recently, for two long weeks, Doctor Rubens laid in a hospital bed, listened to the tales of sickroom staff, and observed what occurred before and after his operation. John took time to reflect on his earlier evaluations, his money, his health, and his life. When circumstances were not as bad as they were today, John chose the retirement that has provided him greater perspective. Frequently, he has mused, ‘There is so much I missed, or just did not understand in the way I do now.’
Time with family, friends was perhaps less than he had hoped it might have been, although he was sincerely committed to his relationships at home, and in the office. John, the Medical Doctor, in private practice, was more often than not, on call. Doctor Rubens loved his work. He chose his profession for the love of people. Physician Rubens entered a consultation room with a desire to heal. He yearned to lend a hand to the patient who wished to help him or her self return to good health.
John took the time to talk and more importantly to listen to his patients. John Michael Rubens was invested in the Doctor Patient Relationship. As he speaks with younger Practitioners, who drop in and then quickly out of his hospital room, John grasps, for them, the Hippocratic oath is a luxury they cannot afford. The current Health Care culture dictates, money matters are the vital sign to be considered. Empathy for a patient has been eliminated from the profession. In the latter years of his practice, Doctor Rubens prescribed as practitioners have, “The changes in medicine are at odds with many of the values that defined the profession I joined”
The physician realized there was a transformation when health insurance companies identified him as a “provider. He was assigned a number. His name was as meaningless as his diagnosis. He spent hours on the telephone in an attempt to advocate for patients. The ill and injured were denied treatment. Payment for prescriptions could not be secured. John recalls when he worked with a particular hospital, months passed and he received no pay. His children, now attorneys argued he should sue. Doctor Rubens preferred to just walk away. Today, he expresses with trepidation, litigation is more prevalent than quality licensed health care.
As the Doctor reminisces, he reflects on the education young interns receive. He hears tales of woe from his daughter-in-law, who is enrolled in a teaching hospital. He reads of how these premier institutions are in crisis. Some experts are anxious. While no one believes the refuge for research, development, and the place in which a patient can receive better medical care will disappear permanently, the money needed to maintain such stellar institutions is no longer a priority in a managed care culture,
As a physician in practice, John knew times were tough. However, he did not fully imagine what it must be like for those who are captive to coverage plans that do not consider the wellness of a patient. Life as one who is in dire need of medical treatment has also opened his eyes. Only days ago, John was in critical condition. He had been rushed to the hospital. Repairs made in a crucial operation years earlier ruptured. Toxins spread throughout his body. The medical professional needed to place his faith, his life in the hands of those who he trusted had stresses of their own. The surgical procedure was deemed a success. Physical pain nearly paralyzed John. His ability to toss or turn was trivial.
Every movement required great effort. When he rang for a nurse, often, no one came, or they arrived long after he alerted them. Ultimately, Doctor Rubens realized if he was to receive adequate care and attention, he would need to hire his own personal nurse to perform tasks that hospital employees could not get to. John Michael Rubens, who is an avid reader, knows the research.
[H]igher patient-to-nurse staffing ratios are associated with higher mortality rates and greater incidence of medical complications and errors, lower job satisfaction, and more burnout among nurses. The findings that follow in this report provide additional insight into the effects of nurse staffing levels from the perspective of the nurses directly providing patient care in hospitals today.
The survey data demonstrate that nurses view understaffing as a serious problem when it comes both to the quality of care that patients receive and to nurse burnout. For example, three in five (59%) hospital nurses say that the staffing level at their hospital is having a negative impact on the quality of care patients receive . . .
The study’s data on patient-to-nurse ratios explain why nurses are so concerned about staffing levels today. Med-Surg nurses report that on average they are caring for 8.0 patients per shift
There are so many people to care for. Yet, circumstances, realities in the Health Care system make this career choice less desirable. The once sought after benefits, and a superior sense of service have virtually been eliminated from the medical profession.
As Doctor Rubens may have heard amongst paid health care specialists, the occupation has been reduced to rituals. Physicians push papers and pills. Nurses administer shots and sponge up urine. Blood is spilled and no one has the time or resources to repair a medical system in distress. The condition is critical.
John feels the pain in the profession he loves. I too worry and wonder. Since we spoke of the dire crisis on the day before this decisive election, I inquired as I had so many time in the past, “Will you vote tomorrow?” Doctor Rubens quickly replied “No.” John sad with apparent sorrow; he assessed John McCain’s Health Care agenda. John saw the Republican leader did not put his country or the citizenry first. Barack Obama, the Physician proclaimed, offers no change that he, personally, could believe in. John Michael Rubens laments today as he did before there was a President-elect, ‘Yes we can; yet, we do not provide adequate care for Americans.’
Sources for a dire situation; Health Care and Medical Coverage in America . . .
- Milwaukee area health care system to cut 74 jobs. Associated Press. Chicago Tribune. November 4, 2008
- Adding Ancillaries : Considerations to Make Before You Take the Plunge. OnFile.
- Patients, doctors cope with Medicare meltdown, By Leah Beth Ward. Yakima Herald-Republic. July 9, 2008
- Fewer Texas Physicians Accepting New Medicare Patients; Payment Cut Would Exacerbate Problem. Medical News. July 10, 2008
- Specialty physician compensation barely keeps up with inflation. Primary care physicians report nominal pay increases despite large increase in production. Medical Group Management Association. July 14, 2008
- Doctors’ income falls over eight years. By Kristen Gerencher. MarketWatch. June 22, 2006
- When Primary Care Slips from Less Pay to No Pay, By Jacob Goldstein. Wall Street Journal. May 16, 2008
- Medicine Grind Hearts Healing Heart. By Benjamin Brewer, M.D. Wall Street Journal. October 30, 2008
- Teaching Hospitals in Crisis, By George J. Church. Time. June 24, 2001
- A Look Inside the Hospital Rankings, How 170 out of 5,453 centers made the cut. By Avery Comarow. USA Today. July 10, 2008
- Patient to Nurse Staffing Ratios: Perspective form Hospital Nurses. AFT Professionals. April 2003