“Don’t worry, doc. It’s just one eye. I’ve got two.”
My stomach lurched to hear this statement. A guy who has done nothing wrong aside from choosing self-employment (and perhaps inheriting less-than-stellar genes) is left with the choice: financial devastation or blindness in one eye. He works hard, has served the country, didn’t complain to me at all, yet here he is about to be swallowed by the ever widening maw of impossible medical expense.
Go to a typical primary care practice (like the one I was in for 18 years) and try to find out the cost of anything and you will only get shrugs and obfuscation. It’s not only that they don’t know what things cost, but the design of the system on which care is built goes out of its way to hide those costs. Why? Because it would be infuriating to people to see that their insurance pays 100% more than someone else’s plan and it would be equally mortifying to some physicians to realize just how bad their pay is compared to the docs down the hall.
For those still unaware (perhaps looking through catalogs for gigantic inflatables for president's day), ICD-10 is the 10th iteration of the coding taxonomy used for diagnosis in our lovely health care system. This system replaces ICD-9, which one would expect from a numerological standpoint (although the folks at Microsoft jumped from Windows 8 to Windows 10, so anything is possible). This change should be cause for great celebration, as ICD-9 was miserably inconsistent and idiosyncratic, having no codes describing weakness of the arms, while having several for being in a horse-drawn vehicle that was struck by a streetcar. Really.
So much bad stuff is (justifiably) said about the healthcare system, and how it is becoming distant, frustrating, impersonal, and dehumanized. That is certainly true in many settings, as we value data, documentation, diagnosis codes, and checklists over the humans for which it's supposedly built. My office is a sanctuary for me, my staff, and my patients from that impersonal world. But the time I spent in the ICU encouraged me greatly, as I saw that people there, in the middle of one of the most stressful settings in my profession, are still caring. They are caring about the work they do, caring about their patients, caring about the families, and caring about doing what is right. In the midst of the hectic world of the ICU, they took the time to talk to me even though I was not at all involved in the patient's care.
Why do patients feel like they are treated like cows, not humans? Why does our system produce more sick people getting more procedures? Why are things so different for the patients in my new practice? It all comes down to one thing: the basic financial transaction of the healthcare system. From it flow all of the bad things doctors and patients experience. From my rejection of it flow all of the wonderful changes to the care I can now give. There is no meaningful reform that can happen without changing this basic transaction.
Some would think that since I no longer accept money from insurance companies, the Affordable Care Act would have less of an effect on me. Those folks may be right in how it directly impacts my practice (since I don't know the actual impact on other doctors, it's not easy to compare), but there has been a significant impact. I've got plenty of ACA stories.
But that's not what I am going to discuss in this post.
My personal adventures with this law are far more interesting from the other side of the insurance card: the health care consumer (AKA patient). It has been quite a ride -- one that has not yet reached its destination.
Changing the focus of care to this is more than just emotional idealism, it is good business. Care should not be about codes, procedures, medications, tests, or interventions, but instead about helping people live their lives with as few problems as possible. We need an economy that thrives when the patient costs the system less.
Any attempt to reform without this change will ultimately fail.
Just a glimpse into the ICD-10 shows how to code the all-too-common problem of when people are injured on railway vehicles (which are not streetcars, mind you). I think it is fitting, when talking about ICD codes, to start with the area of train-wrecks...
The idea of a 'balance' to be disturbed flies in the face of the reality easily seen in this world: few people get through the year without getting sick, and none ultimately avoid getting some terminal condition. In short, fighting sickness is always a losing game.
It looked so easy.... What could be so hard about catching crab in the Bering Sea? Surely I am tough enough for that.
It looked so easy.... What could be so hard about building a practice compatible with the Affordable Care Act? Surely I am smart enough for that.