Conway McLean, DPM, Journal columnist

Modern medicine, as it is practiced today, is a complex phenomenon, multi-faceted and vaguely fractured, incomplete. To the average consumer, it’s a cloudy picture, filled with uncertainty.

Few take the time to educate themselves on how things work, where their health care dollars are going and where they come from. Those who succeed usually do so on their own. Still, too many find themselves lost for answers with too many questions when it comes to the topic.

U.S. health care expenditures are phenomenally high, and considered the most consequential part of the American economy. If health expenditures continue to increase, this will eventually require either increasing taxes or a reduction in spending on important functions like public safety, infrastructure, and education.

Certainly, modern medicine has succeeded in extending life and generally improving the quality of our lives. And yet, these advances have come at a high price. Spending on U.S. health care has grown steadily, increasing from $2,900 per person in 1980 to $11,200 per person in 2018, which amounts to a 290 percent increase. The total monies for healthcare in the U.S. at last count was over $3 trillion.

The steadily increasing health care budget has led to unprecedented pressures on physicians to spend less. As one might expect, this is not first and foremost the goal, in the minds of physicians. When most chose medicine as a career, it was expected it would be challenging, but few foresaw the ways it would be so. The endless paperwork, the bureaucracy, the administrative demands of practicing medicine, all these factors and more have irrevocably changed medical practice.

Modern media gives us an unrealistic view of how a physician spends his time. Studies have shown for every hour physicians spend with patients, face to face, nearly 2 additional hours are spent on desk work in front of the computer. And then, after work, the average is 1 to 2 hours more, writing notes, orders, reports, etc.

Many doctors work 60 to 80 hours per week, and yet, too little of that time is spent with patients. Doctors and staff spend far too many hours attempting to understand and comply with the newest regulations. The economics of maintaining a private medical practice are daunting, more so now than ever before. It’s no wonder burnout remains a constant threat. The unavoidable fact is that unhappy physicians make for a poorer healthcare system

Many older physicians, when questioned anonymously, say they probably wouldn’t have gone into medicine had they known what medical practice would become. We’re not spending our day figuring out how to make people better, but on health insurance issues. Like a patient’s coverage, what treatments and therapies are they eligible for, what services are they covered for. This latter topic is one of those concepts misunderstood by most people, ‘the non-covered service.’ It simply means your plan doesn’t include, and does not provide payment for, that particular service. That’s right: not a cent. The specifics of every plan vary tremendously, making it challenging for practitioners.

Another misconception about modern medical practice relates to the costs of care. How much should be charged when some procedure is performed or a test run? After receiving a statement, doctors are often accused of charging too much. But fees are set by the insurance industry (typically based on Medicare); individual offices have no control of this. In many ways, it almost seems like the insurance companies are trying to make the doctor seem like the villain, pitting the patient against the provider.

Administrative demands have been part of managing patient care for decades, yet the requirements today far exceed anything that came before. Regardless of the type of practice, whether a solo practice or a large group, administrative tasks (paperwork, in other words) come with the terrain. Increasing administrative duties have steadily reduced the efficiency of physicians in providing effective care to their patients.

One of the most trying challenges to the practice of medicine, limiting as they do one’s ability to best treat their patients, is the prior authorization. In essence, this regulatory process means the doctor has to convince some bureaucrat (although sometimes it is a nurse) of the worthiness of some recommendation…..a recommendation made to benefit the health and well-being of their patient. It often takes considerable time away from their patients and essentially forces them to make their case like an attorney, in court, convincing the jurors.

The health insurance industry uses the prior authorization process to limit care, in the minds of many, saving the company from having to pay out benefits for therapy or study. The big insurers have made the argument this “oversight” leads to better care, but few working in the field believe this. Physicians are angered by the wasted time needed for this process, as well as the revenue lost. The stress of negotiating for necessary medications and procedures is often difficult to reconcile.

These stressors and obstacles to providing good care have had a fundamental role in physician burnout, which has become a critical factor in the developing national shortage of physicians. The suicide rate of physicians in the US is the highest of all occupations and almost twice the national average. Many experts believe it is the complexity and inefficiency of the American medical insurance system. Many now see the physician as a villain in the provision of health care.

Some would claim insurance companies have had a largely detrimental effect on the practice of medicine. The endless demands for chart reviews, audits of claims from years previous, even prior authorizations for the simplest of treatments or tests, all have worked to make this a less rewarding career to many physicians. Doctors have little say in the regulatory processes which govern the industry. And we don’t determine the charges linked to each procedure or test, and haven’t for decades, with rare exception.

The bureaucracy in health care administration is staggering; the dollars supporting this labyrinth of paper-pushers is horrendous. And what of the damage that has resulted from our health care quality problems? Likely a question that will never be answered. It would seem medicine has become strictly business, and it is a BIG business. Is our current system for the delivery of health care ethical? Now that is a trillion dollar question.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments at drcmclean@outlook.com.