A ReLACSing Blog #2: Why I’m Leaving the Fee-for-Service Healthcare System, Part Alpha

“I’m done with this place!”

This was a commonly used sentiment by my then 3-4 year-old eldest son when he was, let’s just say, discontent with the household parental unit. Perhaps the scoop of ice cream for his weekend dessert was too small? Did we end the “squeen” time after only two hours and shut off the TV too soon?

However, this is exactly what I’ve been thinking far too often when dealing with the challenges I have faced over the past several years across academic medical centers. For the longest time, I was resigned to the fact that I would eventually have to adapt to the system because changing medical centers resulted in an unchanged experience, just a different medical center name and location. I somehow had to give up providing detail-oriented, counseling-driven, educational, thorough care with close patient follow-up, in favor of “efficiency”. Get patients in and out. Don’t waste time on the details or you’ll spend all of your evenings and weekends trying to complete the patient charts and respond to messages. 

A few years ago, I was talking to two of my former fellowship colleagues–both practicing sleep physicians–and I asked them how in the world some our colleagues can provide a high-level of care for sleep disorders when they spend like 15 minutes in the room with patients, when I’m in there over an hour to address the same ICD-10 diagnostic code. The answers: “They don’t.” “You can’t.” In other words, those who are spending 15 minutes with patients do not provide the same level of treatment and care to patients as those spending 60+ minutes, no matter how efficient you think they may be. You cannot replace the time without sacrificing the detail, the dedication, the personalization, the rapport, and the education. On the one hand, I was relieved that I was not alone in this conflict between providing the appropriate treatment to support optimal health and trying to match the supposed efficiency of the modern day medical center with its short-duration, high-volume visits. On the other hand, since there was no realistic way to do both, I would have to lean heavily to one or the other. However, I finally discovered a system that could support this true dedication to care for patients, without killing myself in the process: direct care. 

I’m a specialist in sleep medicine. I do not profess to be an expert in the healthcare system, I don’t have a degree in economics, and I lack a Master’s of Public Health. However, I’m pretty confident in my surface-level knowledge of the healthcare system as an indentured servant on the inside, as a physician on the ground serving patients. The fee-for-service healthcare system is a disaster. Patients, physicians, nurses, and support staff are caught in the crossfire of a financial battle between the two titans of big business: medical centers and the insurance industry. I am eschewing both as best I can. I’m done with this place. 

The fee-for-service system is set up in way that the more things you do, the more you get paid. If your medical center wants to make money, they better do more things for more patients. There is little emphasis on health. The word health should be excised from the word “healthcare” and excision is a billable procedure in the fee-for-service system! There is no money in lifestyle or prevention. There are diagnostic codes and drugs or procedures to treat said diagnostic code. You only lose time, energy, and money by spending 45 minutes counseling when you could bump up that medication in minutes or order a test that is fairly useless, but hey, it’ll be covered by insurance, make more money for the clinic, and cost the clinic only 10 minutes on the schedule. You screw up the test? You can charge for the test and then order another test. But if you dare to call the patient a few days after making a complex treatment change? Well, you don’t have time to call them because you have to see patients for 10 hours non-stop, slaving away clicking buttons on the electronic health record. If you did, you would not get paid for the effort following up with the patient. If the patient really needs help, they can send a portal message, and an admin can forward it to the nurse, and the nurse could call a day later, and then maybe run it by the doctor, but the doctor is not available, so they run it by the physician assistant, but you will never talk to the doctor because he or she is seeing 30 patients and does not have time to talk to anyone on the phone. Or you could be one of those 30 patients seen by the doctor, but you get a 10 minute slot and the next available is in…how about 6-8 weeks?

In the field of sleep medicine, sleep centers get paid through sleep studies, with the overnight sleep study (polysomnogram/PSG) being the gold standard for the fee-for-service payment model and the most effective way to turn a profit. Most of the sleep studies I interpret on a weekly basis can be done away with if the system did not feed into them. However, the insurance may pay the medical center as much for one sleep study as a half day’s worth of patient clinic visits.  Needless to say, the physicians and the medical center have every financial incentive to do as many sleep studies as possible, without any question as to whether these are beneficial to patient care. As a subspecialist in restless legs syndrome (RLS), for example, I have had many patients who have had sleep studies done when they went to the sleep clinic for RLS, a condition that is diagnosed exclusively by asking questions based on symptoms. There is minimal benefit of doing a sleep study for RLS, and patients are often confused as to why they needed one. They did not need one. The sleep center needed the study to get paid. The insurance was not going to reimburse them sufficiently for just spending the time and effort, working with the patient, and helping their condition. Spending an hour discussing RLS with the patient was not the way to get paid. The same could be said for most other sleep concerns, which mostly require significant education and counseling.

As a physician who puts the health of my patients first, I just cannot roll like this. I’m going to work with patients on cognitive and behavioral changes to sleep to help with insomnia, even if it takes 30 minutes and multiple sessions, rather than spend 5 minutes throwing out the latest and greatest sleeping pill that will be lucky to work for two weeks if at all. Instead of seeing an RLS patient for 10 minutes and bumping up the dose of their dopamine agonist (which should never be prescribed for RLS, by the way) to relieve the symptoms for a few more months, before things worsen again, I educate patients on the real causes of RLS and the changes they will need to take in a stepwise manner to improve the condition. The treatments and their effects or side-effects are explained in detail. These are not procedures. This approach will take time, energy, dedication, and follow-through, and not usually another sleep study. And those features will not lead to greater reimbursement by the fee-for-service insurance system. Thus, the effort is not monetarily valued by the business model of the medical center. And that’s why I’m done with this place. To be continued next week…

-Andy Berkowski, MD

ReLACS Health