Mental Costs of Healthcare Insurance towards Burnout
Continuing on my burnout discussion from a few days, I wanted to touch upon another area or factor that might explain why medicine has one of the highest burnout rates in most professions. As I did more research and reading, I found that in an editorial published in the Journal of General Internal Medicine, that burnout rates range from 30-65% across all of the medical specialties.
In the article, it mentions some of the cons of physician burnout, many of which I had mentioned in the first post, namely that those facing the highest rates of burnout are also in the specialties that have some of the lowest matriculation rates, most likely related to the fact that medical students also perceive the potential stress in a primary/front line care career. Some problems posed, can affect both the health care organization but also the patients as well. As I mentioned before, physicians try to maintain quality of care despite their own inabilities to manage their own, and as a result, it can be associated with poorer care quality. Additionally, if these burned out physicians do happen to leave, the costs of replacement can also be very high because it is getting harder to find physicians of certain specializations. Nowadays, pre-med students and medical students alike, realize that medicine is no longer nearly as profitable as it was back in the day, and although it is considered somewhat of a “gum fan woon” in Chinese, or translated into the “golden rice bowl” meaning that it can always provide a means of subsistence, students are looking to jump into those high paying specialties. Unfortunately, this is starting to create a gap and shortage of primary care doctors (though there is a bureaucratic and political reasoning behind that, due to the compensation of insurance and a federally mandated “relative value unit”)
Just from this article, they write that doctors are 15 times more likely to burn out than professionals in any other line of work, and that 45% of primary care physicians would quit if they could afford to. As I mentioned before, it doesn’t only affect the physician, but also those around them, in that physicians have a 10 to 20 percent higher divorce rate than the general population.
And with that, for today’s post, I want to speak on a more specific level of burnout, burnout faced by primary care physicians as well as those that work in understaffed/rural locations throughout the United States. I want to speak more about the costs of healthcare and as a result, tack this on as an extension to the crippling debt that many newly minted physicians have to face. Instead of just talking about the costs of education, I want to discuss kind of the current situation that these primary care physicians face in regards to what the receive in return for the hours of dedicated work that they put in. Now, bear with me for the next few hundred words. It might not make too much sense, but I’m going to come full circle at the end and hopefully it’ll be clear why the following is such an important factor in regards to federal and state (because of financial inheritance) declared compensation values for insurance.
*I had the chance to speak to a couple of family physician friends as well as some physicians that I had shadowed before, about their thoughts on the subject. Some of them range in their 30’s while some of them are in their 50’s, pushing 60’s, so I could have had a wide range of opinions and perspectives. Names will be omitted.
Now for many primary care physicians, they will either work in private practice or as hospitalists in general. This is just a broad blanket statement, but for those that work in private practice, depending on the location, it can be a very financially tight career. Although private insurance compensates much more that what the federal government does for Medicare and Medicaid, a majority of patients seen will typically have either state or federally funded insurance, and as a result, the compensation is based off of “relative value units”. In these situations, the reimbursements in the US, have no relation to supply and demand, and only a little bit of relation to cost of living inflation throughout. In the end, one of the reason the medical technology and health IT was pushed so hard in these past few years was to be able to manage finances, billing, insurance claims, and metrics. That’s the cold hard truth, and unfortunately, health care providers were but an afterthought in the design.
Now, one of the most important innovations in health IT are “codes”. I’m not going to get into it, but there are a variety of codes that can be used to designate different diagnoses, insurance types, payment options etc., but these codes are submitted to a federal committee called the Relative Value Update Committee (RUC) which is comprised of representatives of all specialties/subspecialties and this group then “values” the code by recommending that it be assigned a certain number of “relative value units” (RVUs). These RVUs are then used to determine the financial compensation to medical procedures, adjusted to cost of living and other forms of inflation. An RVU assignment is supposed to reflect not only time, but acuity, risk, and need for specialized training. Once these RVUs are assigned it (almost literally but not quite) requires an act of congress to get them changed, so they certainly do not reflect changes in supply and demand in any sort of real-time. So as I mentioned above, the federal government has declared that 15 minutes of curing your blindness by removing a cataract (plus the office visit to discuss it and the follow-up) is “worth” more than 15 minutes of discussing whether or not you should take a prescription medicine that will lower your risk of heart attack 20 years from now. Because of the necessary oversight required, this has led to problems with both oversupply and shortages, due to the inefficient and politically-driven pricing. Now, I mentioned that the committee is made up of representatives from all specialties/subspecialties, so surely there would have been talks to increase the RVUs for more preventative and primary care compensation costs, but when a majority of these representatives are specialists, it’s a matter of self-preservation and the idea of “why should I increase the compensation for something unrelated to me, and lose out on compensation for what I am doing?” and as selfish as that may seem, it’s what happens. Now because these primary care physicians realize that government-funded insurance compensations simply aren’t cutting it anymore, as in the cost of treatment is more than the compensation, some are starting to specify what kind of insurance is accepted or it’ll be a cash-up-front practice. Local county hospitals and clinics won’t be as lucky, as they will continue hemorrhage money. In more populated areas, that isn’t as much of a problem as there is a larger population of physicians and because of competition they will be more lenient in what kind of insurance is accepted, because within a certain population, there always has to be a certain number of physicians that take government-funded insurance. But in smaller cities and rural locations where they may be only one or two physicians, this can be a nightmare as the cost of treatment has to be swallowed, and in one case that I know of, a private practice had to shut down because they were simply in the red for too long.
Healthcare, social justice, and policy are not mutually exclusive. Our individual and collective health – physical, emotional, psychological, and even socioeconomic – is directly affected by unregulated Big Pharma and U.S. health insurance companies. It is imperative we educate ourselves, hold the system and those who perpetuate it accountable, and demand for regulation reform. The more sociopathic you are, the more capitalism rewards you. This is why capitalism requires regulation. Although the RUC and RVUs play a role, it’s also because of the current state of capitalism and lack of regulation or enforced oversight that allows for such things to happen.
When a large group of primary care physicians command a significant percent of business in a given area, they are in a good position to bargain for higher fees from local insurers. What happens, then, when insurers gain market share? In part, they are in a position to negotiate for lower provider fees. That is why health insurance mergers could potentially reduce health care prices. Why do I say “could” instead of “will?”
First, if providers consolidate faster or more effectively than payers, they will still hold the upper hand in negotiating prices. I don’t pretend to have any idea of how this particular horse race is going to play out.
Second, there will probably be legal challenges to consolidation on both the payer and provider side. I don’t pretend to even pretend to know the outcome of these legal actions.
Third, when payers consolidate, they not only gain more power over providers, but, also more power over enrollees. Large, dominant insurance companies might be able to get away with charging higher premiums for their insurance plans. Their ability to do this will depend in part on how sensitive potential enrollees are to the price of insurance plans, and to how aggressive local regulators are about limiting premium hikes.
In this capitalistic “free market” that we have in the United States, private health care insurance organizations are also culprits in medical cost gouging. Although they aren’t contributing to the same kind of stress that federal and state-wide insurance compensations are smashing down the healthcare system, they’re still another factor to consider. Whereas the compensations are going down more and more, the costs of private insurance is rising more and more as these large organizations are gaining more and more market share, thus it can bar certain income levels from purchasing private insurance and thus they default to the federal and state-wide insurance, thus increasing the pool of health care users that ends up providing substandard insurance compensations.
Unfortunately, the affordable care act compounded this issue a little more because there are now federally-funded health insurance exchanges that give people more access to this form of insurance, but with that comes the lower compensation rates. In order to combat these lower compensation rates, physicians everywhere are starting to try and see more patients in a day, thus reducing the patient-physician interactions and more importantly, decreasing the actual time that you’re being seen by a healthcare provider.
Do you see where I’m getting to now? Is this all starting to come full circle as to why all the political and bureaucratic red tape is leading to physician burnout? In order to keep doors open, in order to keep private business and their own livelihoods afloat, many primary care physicians are trying to shove more and more work into a day, and as a result it gets to you in time. A close friend of mine commented that he takes his work home, not just physically but mentally in that he can’t turn his brain off at the end of the day so that it consumes him. If these people quit, especially those in the rural areas, then what? People are losing out on access, people are losing out on quality of health, people are losing out on opportunities to better themselves.
Well that about wraps it up for today’s post, I know that this was a dense read and that I’ve kind of diverged from my tongue in cheek, humorous style of writing, but I promise that I’ll get back to that soon! This is just a topic that speaks seriously to me and I feel that if I wrote about it with a humorous tone, I wouldn’t have been able to write it with the necessary gravity and emphasis that I was aiming to convey. In the end, I hope that you all have a great day and continue sending me those emails! I love receiving them and responding to them, and it’s great to know that there are so many IT and healthcare professionals that are receiving my posts with such kindness and critique!