The Doctor Can’t See You Now
Disease prevention and health promotion were supposed to be the cornerstones of our new “managed” health care system. Managed care promised to cut costs and prevent suffering by shifting the medical system’s focus from episodic treatment of acute crises to preventing those crises. But along with promised reductions in the cost of health care, a serious commitment to preventive health care has not materialized.
Although most people tend to equate preventive medicine with high-tech screening tests for breast, ovarian and prostate cancer or elevated blood pressure and cholesterol levels, this doesn’t prevent problems. Such tests simply detect problems earlier. They often lead to aggressive treatment even when, in the long run, it might not be effective.
Real preventive medicine, on the other hand, involves conversations between clinicians and patients. When patients establish trusting relationships with their clinicians, they will be more apt to heed warnings about diet and exercise, tobacco, alcohol and drug abuse and reveal potentially problematic health behaviors. After all, if getting people to stop dangerous behaviors were just a matter of handing out videos and pieces of paper, we’d all look like Tom Cruise and Nicole Kidman, and the tobacco industry and AIDS would be distant memories.
Well, when was the last time your doctor had the time to probe your life for signs of dangerous health behaviors? When was the last time you even got to see the same doctor or nurse practitioner twice in a row?
The fact is, in our market-driven health care system, a real commitment to health education and disease prevention just doesn’t make rational economic sense. Prevention and health education generally pay off only over the long-term. If I persuade you to stop smoking today, the benefits will occur decades in the future. But the employers and insurers who now govern our health care system have their eye on the quarterly profit statement, not on the year 2020. Most employees won’t be employed by the same company 30 years from now. Nor will most enrollees be insured by the same HMO.
Alan Sager and his colleagues at Boston University School of Public Health’s Access and Affordability Project analyzed Massachusetts disenrollment rates from HMOs between July and September of 1995. They calculated that after seven years, only one-quarter remain. “Given these disenrollment rates, no financially sensitive HMO would be motivated to invest in prevention and health education,” Sager concludes.
HMOs also defeat prevention by burdening clinicians with huge patient loads. HMOs either directly or indirectly encourage quantity over quality. With thousands of patients assigned to each physician or nurse practitioner, the normal office visit is now seven to 15 minutes. “I’d like to do a lot more talking to people about safe sex, domestic violence, and I don’t get to do that in a 10- to 15-minute appointment,” says Joan Bloom, a nurse practitioner in obstetrics and gynecology at Kaiser Oakland.
To make up for lack of time with caregivers, Kaiser and other HMOs have developed libraries and classes patients can use to get health information. But these are no replacement for one-to-one conversation and tend to be used only by highly motivated patients.
Patients can feel the results of the pressure on their clinicians. “Kaiser used to send you a notice every two years to come and get your routine physical,” one frustrated enrollee reported. “Now you have to call over and over again, only to receive a postcard informing you of when to come in. Of course, since they don’t ask if you can come at that time, you then have to go through the whole process all over again to cancel and reschedule.”
What’s more, when patients finally get into the office, they find it increasingly difficult to hold their physician’s attention. After she waited more than 2 1/2 hours for her appointment, this Kaiser patient tried to talk to her doctor about an urgent physical problem. Instead of engaging with her, he used a classic method of getting a patient out of the office. He reached for a drug company pamphlet, told her she was clinically depressed and handed her a prescription.
Caregivers can be persuaded to make long-term investments in their patients’ well-being. But only if financial incentives encourage them to do so and if patients remain around long enough for the investment to pay off--in ways that reduce suffering and save money and lives. What’s needed is a new American health care system--a universal system that puts us all into the same pool, ends competition around cost-cutting and channels money to patient education and care rather than profit. Until that happens, HMOs will continue to bribe doctors and hospitals to both underserve and undereducate patients.
