How Did Medical Care Get to This Point?

The reasons are complex, but I think they can be boiled down to two facts: 1) the Payers who actually pay the most money are insurance companies (including Medicare), but 2) in order for these “Third Party Payers” to (understandably) make sure that the doctor being paid is not completely defrauding them (charging for patients never seen, for example), the Payers need proof.  

Insurance isn't evil, but they don't care for you--  They don't even know you

Third Party Payers are occasionally defrauded, and over time, they have always demanded more paperwork.  The devil is in the details.  Doctors got on the hook taking the insurance money starting 50 years ago, because it helped pay and keep the doors open, but the bar is being continuously raised.  This might sound good, but every physician in America knows that unfortunately, the “standards” are frequently meaningless, and they always add to the enormous bureaucracy. 

This bureaucracy is not only in government and insurance, but in every participating doctor’s office.  In fact, Medicare and insurance companies do not provide care—they do not “care” for anyone.  They are institutions that only survive if more income comes in than the expenses paid out.  So failing to pay the doctor, or just rejecting/obstructing payment (hopefully until the doctor gives up) is, sadly, in their interest. 

How Doctors collect 40 cents on the dollar... or less

In short, for doctors to collect money from insurance, they need to pay a lot of money—expensive (and mandatory) electronic medical records; taking coursework in how to charge bills so they won’t be rejected; hiring staff to do the billing; and it adds up to a huge overhead cost.   All physicians in this system know what “the business people” will recommend for balancing the office budget, because it’s always the same: “see more patients.”  Doctors generally make more money by seeing patients for numerous 5-7 minute visits. 

Of course, there are doctors who spend more time; most doctors variably do, where they can.  But to satisfy all the proofs and documentation for Third Party Payers, doctors spend more time on the computer (documenting our interactions and dealing with ancillary paperwork from insurers/ pharmacies and consultants) than with the actual patients.  

Working for what you are allowed to charge

It's worth noting that as the single largest payer, CMS (Medicare and Medicaid) have failed to keep up with inflation for decades.  If a doctor takes a single charge for any Medicare patient, then they are obligated to participate in every rule, regulation, and limitation of that system--- including accepting the Medicare rates.  The doctor that charges more (or less!) is at risk for findings of fraud, fines, and even imprisonment.

How's the doctor supposed to make money?

So to see a full day of patients, some providers see 4 patients/hour, spend 5-7 minutes actually talking with them, and can be finished with the note before the next one appears.  If the doctor actually spends that 15 minutes with each patient, the doctor will then spend 6-8 hours documenting the notes after hours.  These pressures are far harder on primary care providers, who are called upon to write prescriptions, work excuses, FMLA, and Home Health Nursing orders for the subspecialists who do procedures, are paid handsomely, then “defer to primary care provider.” 

I have always resisted compromising time with patients, and in fact very often plan 30 minutes or more.  I have been comfortable with this practice.  However, the problems of “quality” with the 5 minute visit are being recognized by the Third Party Payers, who are now trying to “prove” that they are getting good value for their money.  Unfortunately, while results of such are always arguable, yet this push has translated, as always, into ever more burdensome documentation.  It has only gotten worse for 20 years, and will likely continue