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Dr. Eric Reinhart’s recent New York Times guest essay, Doctors Aren’t Burned Out From Overwork. We’re Demoralized by Our Health System, makes three astute observations:


First, people are losing faith in our increasingly dysfunctional health system. Second, physicians are demoralized, feeling “helplessness and [experiencing a] loss of purpose.” Third, the billing system is to blame, dictating "...every aspect of medical practice, producing not just endless paperwork, but also subtly shaping treatment choices.”


We desperately need solutions to these problems. However, before seeking solutions we need to understand the cause of our problems.


After 45 years of working on all aspects of healthcare, my view is that coding and Fee For Service payment is the underlying problem. This payment model depends on volume of care not quality of care. This payment model does not compensate physicians for talking with patients nor does it compensate physicians for talking with one another about common patients. A payment system designed to push the volume of tests and procedures while discouraging conversation is our core problem. Conversations are a critical element of quality healthcare. Discouraging these conversations has caused both patients and caregivers to lose faith in the system.


The second underlying problem is a payment model that is based upon cross subsidization. The inequities outlined in this article largely stem from a cross-subsidized payments system. Specifically, some insurers pay slightly less than the healthcare provider's cost (Medicare), and some pay substantially less than a provider's cost (Medicaid and the uninsured). Meanwhile, commercial insurers pick up the difference. Providers are forced to control their mix of patients from these differing payment levels from insurers. This system obviously is not good for patients or providers. It requires providers to avoid poorly paying insurance - which means avoiding poor patients. Our payment model inevitably forces inequality.


Our coding system also forces cross-subsidization by treatments. Some treatment services like surgery pay well. Other treatment services like primary care pay poorly. The result is that surgery is easily available and primary care is not. Coding creates inequality by illness. This payment model is depressing for doctors and patients.


The third underlying problem is that the administrative requirements in healthcare are excessive and complex. Today, physicians spend 49 percent of their time on these administrative burdens compared to 29 percent of their time with patients. No wonder everyone has lost faith in the system. There are two primary causes of this administrative burden: one is coding and the second is fear of violating fraud and abuse regulations. Coding and fraud and abuse regulations today are so complex that a new industry was created to manage it: revenue cycle management. It is a lucrative business - last year we spent $140.4 billion on it. As a source of comparison, the entire US auto industry generated $100.4 billion last year. All this unnecessary cost is incurred because of coding and fraud and abuse documentation.


You might ask why we need fraud and abuse oversight. It’s because our payment model encourages volume and coding manipulation. Is fraud and abuse oversight effective? Based on the growing costs in healthcare, it doesn't seem so. I do know its regulations are extremely expensive. If we did not pay providers based on coding and volume we would not need coding or fraud and abuse oversight. If we didn't use this payment model, physicians would have time to talk with patients, coordinate care, and have a career doing what they spent so many years learning to do.


There is an alternative payment model. The solution is to have insurers pay the physicians a salary based on their expertise and quality. Virtually all other professionals are paid on this formula.


The mechanics of this solution is well beyond the scope of this letter. My forthcoming book, The Journey’s End: An Investigation of Death and Dying in Modern America, offers a more thorough explanation. Consider it a morale booster.

Updated: Feb 10, 2023

Since the Enlightenment, we’ve favored science over intangibles like wisdom and art. This belief in science gives us the illusion of control but even science has its limits. Our dependence on scientific evidence has come at the cost of losing common sense, especially in the practice of medicine.


While medicine was once seen as both an art and a science, our focus evolved and today, medical school teaching is based almost exclusively on scientific principles. The impact on medical education has been both beneficial and profound but it has diminished the important role of art in medicine.


Until the middle of the last century, it was not uncommon for doctors in this country to forge a personal bond with their patients. Many MDs were general practitioners who treated and knew virtually every member of the family.


Now, technology plays the dominant role in the diagnosis and treatment of patients, even those who are dying.


Don’t get me wrong. The shift toward specialization and science in medicine has brought undeniable benefits such as the miracle drugs and sophisticated treatments we have developed for diagnosing and curing the sick and the injured. However, there is

a downside, particularly when it comes to providing artful and compassionate end of life care. Too often we try to keep dying patients physically alive by using advanced medical techniques despite the impossibility of their ultimate recovery. Instead of calling on science to artificially extend their lives, we should be using our basic human decency and common sense—the artful side of medicine—to help them die naturally.


While we invest generously in medical technology, we don’t fund critical, non-medical support like homecare, which is especially important for the frail and elderly. We also fall woefully short in providing palliative and hospice care to terminal patients who would prefer to die at home rather than in a hospital.


By relying almost exclusively on procedures and tests in our treatment of dying patients, we take the art and humanity out of medicine. Our scientific approach overwhelms spiritual and psychological considerations such as the emotional well-being of the patient.


The Hippocratic approach to medicine called on physicians to be “very kind to the patient.” The approach specified gentle treatment and “emphasized keeping the patient clean and sterile.”


This kinder, gentler approach to medicine, employing empathy and intuition, is especially important in treating patients in the last years of their life. By connecting personally with their patients and granting them the dignity and respect that they deserve, doctors can do more to ease their dread and discomfort than any inanimate machine no matter how sophisticated or efficient it may be. The more machines dying patients are hooked up to, the lonelier, more hopeless, and more isolated they are likely to feel in their final hours and days.


There are patients who will not want to give up the fight for life and that is their choice. Might their choices change if they had data that informed them of likely complications from certain treatment options?


If, for example, as an older patient you knew that you were at increased risk for reduced cognitive and physical abilities and greater risk for nursing home placement following successful medical treatment for a heart attack, would you feel the same way about receiving that care? Providing older patients with this kind of data can help them make more informed choices about their EOL care. Medicine can save your life, but it can extract a heavy toll, too.


Through the synthesis of science and art we are more likely to find a good death. What might the therapeutic art of medicine look like in the dying process? How do we wish to face death? This is a humanitarian – or “art” - question more than a scientific one.


Our cultural bias toward science has deprioritized the hospice care option. Hospice is a humanitarian and not a science-based model. Selecting hospice means the patient or his or her representative is letting go of further medical treatments. While it can be hard to make the decision to let go, research has documented that life expectancy is just as long, if not longer, in hospice care.


This research reminds me of a blunt quote from a physician advising her patient about a chemotherapy regime: “You probably have six months left to live. You can take chemotherapy and you will suffer through those six months, or you can go into hospice and spend that time putting your affairs together with your family.”


The point here is that death involves making complicated personal and clinical choices. Do we want chemotherapy, or do we want hospice? Such dilemmas would benefit from a therapeutic perspective and humanitarian reflection – in other words, a balance of art and science.


If you’re interested in reading more on this topic, my book is available for pre-order here. Use code RLFANDF30 for 30% off. #EOL

Reforming Medicare enrollment and simplifying Advance Directives are passions for Dr. Kevin Haselhorst. In this podcast he argues that most Advance Directives are confusing for caregivers and families and he cites well-documented research to substantiate that point. Dr. Haselhorst does believe Advance Directives are a critical tool for patients and healthcare, however, they need to be simplified. He suggests two strategies for simplification.


First, have a patient select one of three treat options for end-of-life care:

  • Proactive inpatient hospitalization

  • Comfort care in the home

  • Palliative care in the outpatient setting

Second, make completing an advanced directive mandatory at enrollment with Medicare and require Medicare recipients to review the directive annually as part of the annual Medicare Wellness visit.


The podcast provides several patient care examples to illustrate why Dr. Haselhort’s recommendations are advisable. He invites patients to assume much greater responsibility for their own end-of-life care. In essence, he is suggesting we need to engage individuals into becoming more informed about their end-of-life choices. Making the three simple choices he suggests would be powerful, but these choices are only feasible if the individual understands the implications of those choices.


My book, The Journey’s End, makes similar recommendations. The book outlines many of the challenges making the implementation of these recommendations feasible. As Dr. Haselhorst acknowledges, one of the biggest challenges is that the vocabulary for all these choices is confusing and inconsistent. The Medicare insurance world, the clinical world and the legal world each contribute to this confusion.


The Journey’s End helps patients become informed about these choices and offers health reform recommendations to make their implementation feasible. If you’re interested in reading more on this topic, my book is available for pre-order. Use code RLFANDF30 for 30% off.

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