Earlier this week I met my mom for her medical appointment and we waited one hour past her appointment time to even be put into a room. When I asked about the wait, the front office staff checked with the back office. Maybe the clerk was trying to put the best spin on the doctor running late, but I didn’t find it comforting to learn that, “at least it was only an hour, because in West LA you can wait 2-3”.
My mom recently moved over to the UCLA health care system and I am glad she did. Both of her new doctors are engaged in her care in a manner that was missing with her previous physicians. In a word the quality of care has improved, but the system is clearly strained if not broken.
THE BEST MEDICAL CARE IN THE WORLD–NOT SO MUCH ANYMORE
I can’t remember the last time I heard somebody crow that Americans enjoy the best medical care in the world. Lately, I haven’t folks quip that we enjoy the best medical care money can buy. Maybe that is because I don’t see too many clients who enjoy the privilege of paying for “concierge” service, where a hefty out of pocket fee guarantees access to your doc 24/7.
In the world of everyday medical care, my sense is that the current system is struggling to offer care to the masses of newly insured. This was mom’s second visit to this primary physician, with a goal of reassessing her medication. Soon I understood just how this doctor found herself an hour behind at just 11am in the morning. Our physician told us that UCLA recently reset appointment times so that new patients would be seen for only 30 minutes instead of an hour; follow up visits are similarly cut in half from 30 minutes to 15. I wonder if they think the patients won’t notice. I can’t help but feel sorry for those charged with delivering care.
MEDICAL CARE VERSUS CHECKING OFF BOXES
With so much time to chat, my mom piped up that she hears the seniors at her assisted living facility complaining about the same thing at all facilities. I haven’t read about it, but maybe we should be talking about it more. Certainly, opponents of The Affordable Care Act will be swift to demonize Obamacare for the problem, but I don’t believe providing insurance for millions more Americans is the real issue. A profit based system probably is.
A profit based system mostly offers care that makes money. As long as people can’t afford medical care, there is no incentive to train and staff adequate medical support to meet the needs of all Americans–not just those who could access and afford medical care in the old system. Maybe as long as the most needy of the masses huddled for hours in emergency rooms, the rest of us were left to think the system was working well enough.
Now that a good percentage of those masses have access to conventional medical care, we all feel the strain. The nurse, the doctor and the front desk staff all told us the same thing, “It’s not going to get any better.” How long before the strain cracks the most dedicated clinicians and staff? I started to consider what needs to change.
A FEW IDEAS FOR A NEEDED REBOOT
As I sat with my mom, I pondered what could ease the strain on everyone. When it comes to appointments and the front office, someone needs to figure out how to communicate with patients in real time. If the doctor is running 1 or 3 hours late, there should be an app for that. Let folks know so that they can stop rushing to make their appointment time, maybe run errands, take a minute to have lunch, or go for a walk. I had to bite my tongue when a nurse suggested that next time I should bring a book.
In the back office, we need to take more off of the doctor’s plate. I needed the doctor’s expertise to assess mom’s current medical condition and medications, but after identifying that meds that could be discontinued or adjusted, I can imagine a PharmD would have been equally effective in adjusting the doses and discussing ramifications, freeing up the doctor’s time to assess another patient.
KNOWLEDGE IS NOT BEHAVIOR
As we discussed discontinuing a calcium supplement for my mom, I wondered why the doctor was charged with explaining rich sources of dietary calcium to us. I already disclosed that I am a dietitian, so she didn’t need to waste those precious seconds. However for every other patient, when will we acknowledge that telling people rich sources of calcium is the lamest excuse for nutrition counseling? Yes, those few words allow the clinician to check off the box, but there is little in that exchange that is likely to elicit behavior change.
Soon two other boxes were checked as well. Mom’s elevated A1C indicates an increasing risk of diabetes, and the doctor suggested medication, without discussing diet or exercise. I interjected and we decided for many reasons that mom may be better off giving more attention to diet and exercise. What a concept.
Mom was also told to decrease sodium, as her blood pressure was elevated for the first time in years. I knew it was most likely because mom was anxious about me, and feeling bad. The doctor’s running late meant that I was going to be late for my own appointments. But the doctor didn’t know that because she didn’t ask, and mostly I don’t blame her. She had fallen even more behind during mom’s visit.
WHY DO WE EXPECT DOCTORS TO DO IT ALL?
We train doctors to diagnose and treat, but we don’t provide them with the time and resources to counsel patients about life skills, self regulation, and other process-oriented care. On top of everything else they do, how are they to adequately address food and nutrition, including the complex dynamics involved with energy metabolism, nutrition adequacy, food processing and exercise science, perception of hunger and satiety, stress and time management, interactions with medications, as well as the mundane tasks of shopping for food, preparing a meal, or eating away from home? In addition, what about the emotional, social, and cultural factors that influence an eater’s choice?
I wonder if we have institutionalized the time crunch by expecting doctors to do it all. Time probably presents the greatest obstacle, especially as the system bumbles along with too few primary care physicians.
A couple years ago I scanned the list of experts who proposed how to treat obesity as authorized by the Centers of Medicaid and Medicare Services, every one an MD. Despite that treating obesity is not the same as treating the flu, appointments are limited to 15 minutes, can’t occur during regular office visits, and are reimbursed at the princely sum of $27.50. I understand that a primary goal was to contain costs, but they also succeeded in containing access and probably effectiveness as well.
WHY AREN’T WE USING DIETITIANS TO THE FULLEST EXTENT POSSIBLE?
What physicians really need to learn is how to refer effectively. But physician referrals aren’t what they could be, mostly because nutrition counseling for everything other than diabetes and renal disease is not routinely reimbursed by medicare.
Private insurer’s follow medicare’s lead, and institute their own barriers to care. For years insurance carriers refused to acknowledge dietitians as providers. Now that insurance companies accept dietitians as providers, I find they have other ways of limiting access, sometimes by limiting the number of dietitians they accept as providers, others by offering such limited reimbursement fees that few dietitians are motivated to sign up as providers in the first place. I have even seen employee contracts that specifically red line medical nutrition therapy as a covered benefit.
Much needs to be repaired or rebuilt for medical care to meet our changing needs. Better access to nutrition counseling and medical nutrition therapy could be part of the solution, as dietitians are educated, trained and available to do this work, with plenty of evidence that medical nutrition therapy works and is cost effective. If medicine is truly concerned about patient health, and as conventional medicine continues to struggle with too many patients for too few primary care providers, why isn’t there more insistence that we use dietitians to the fullest capacity possible?