When I retired at 70 years old as a practicing geriatrician in Wilmington and said farewell to my medical colleagues, I slowly began to realize that I might be “The Last Happy Doctor” in town. Why is this and how did it happen? First, let me lay out some of the realities of practicing medicine today.
The surgeon general has declared that, second only to opioid addiction, “burned out” physicians is our most critical issue in health care. In a recent survey of N.C. physicians, the most prominent reason given for their “burnout” was erosion of clinical authority and the requirement of excessive insurance paperwork in order to get paid. Only 11 percent of physicians felt they had the time they needed to provide the highest standards of care. In the next one to three years, 44 percent plan to cut back on direct delivery of care, retire, or seek work in non-clinical jobs.
So, how did I end up as the “Last Happy Doctor”? It was a series of responses I made as the insurance industry began to reshape health care as a for-profit efficiency driven business. The first choice was to resist reducing the time spent with my patients. When I refused to schedule less than one half hour per patient, it became obvious that I would need to start and manage my own practice. Because of my choice to focus primarily on caring for older patients, my revenue stream was approximately 96 percent Medicare funded. Unaware, I had wandered into a “Medicare for All” financed healthcare practice.
Knowing that all my patients had coverage was a great relief to me and my office staff. That allowed us to focus on truly caring for and about them. Having a predictable reimbursement allowed me to create a budget. The greatest bonus was the lower overhead. Because my practice did not need to spend hours on the phone with agents of the for-profit insurance companies, I could hire fewer staff. Additionally, not only was I making clinical decisions based on patients’ needs, I got to decide on clinician-friendly computer software for data collection. This reduced the other major reason physicians are “burned out” and leaving practice: spending excessive time using computer software that does not actually serve any meaningful purpose for clinical care.
The introduction of widespread for-profit insurance financing of health care in the 1970s is a major factor in the demoralization of physicians. The percentage of the health care insurance market served by for-profits rose from 16 percent in 1981 to 65 percent in 1997. In the for-profit setting, physicians are required to care for patients under constant time pressure and with the knowledge that the cost of care may send their patients into bankruptcy. This model does not work in health care at the practitioner level because it requires reduction of human contact time. Without this human contact, a loss of satisfaction occurs for both the physicians and patients. Critical to the discussion is the significant lowering of survival rates and desired patient outcomes since 1950, all in the context of rapidly rising costs.
In a humane society, universal health care is a given, and those involved in health care optimally come with a calling. Helping individuals improve their health requires trusting relationships over time. Creating a “Medicare for All” financing system and removing for-profit insurers from the equation is an appropriate pathway to less expensive care, better health outcomes, happier patients and happier doctors. I know because I have been there.
Fretwell is retired from active practice in geriatric medicine. She is now activity working with Healthcare for All of Western North Carolina seeking fundamental change in the financing of health care.