Studies in Social Medicine

The Journey through the Health Care System

Muriel R. Gillick, M.D.

• Publisher: The University of North Carolina Press
• Year: 2017
• ISBN:
  9781469635255
• Topic: Medicine
• Subtopic: Health Policy

Since the introduction of Medicare and Medicaid in 1965, the American health care system has steadily grown in size and complexity. Muriel R. Gillick takes readers on a narrative tour of American health care, incorporating the stories of older patients as they travel from the doctor's office to the hospital to the skilled nursing facility, and examining the influence of forces as diverse as pharmaceutical corporations, device manufacturers, and health insurance companies on their experience. A scholar who has practiced medicine for over thirty years, Gillick offers readers an informed and straightforward view of health care from the ground up, revealing that many crucial medical decisions are based not on what is best for the patient but rather on outside forces, sometimes to the detriment of patient health and quality of life. Gillick suggests a broadly imagined patient-centered reform of the health care system with Medicare as the engine of change, a transformation that would be mediated through accountability, cost-effectiveness, and culture change.

Part I

The Office

CHAPTER ONE

Going to the Doctor

Every so often during my years as a primary care geriatrician, a new patient landed in my practice who hadn’t seen a doctor for forty or fifty years. Sometimes, the last direct personal encounter with a physician had been during childbirth. I faced patients like that with a shiver of dread because they usually turned out to have something terrible wrong with them, like the woman who had been healthy all her life, who exercised regularly and ate a good diet, and who came to see me because she’d woken up one day feeling as though she’d been hit by a Mack truck. She might as well have been hit by a truck: she proved to have widely metastatic cancer and would be dead within six weeks. Or there was the 82-year-old woman who had never been sick a day in her life and, according to her, still wasn’t. She was dragged into the office over her vociferous protests by her son and daughter because she went out into the snow wearing sandals and left the teapot burning on the stove long after all the water had evaporated. She had Alzheimer’s disease which had progressed to the point where she could no longer safely live alone. Her judgment, markedly impaired by her dementia, didn’t allow her to grasp her situation. She refused to accept the various creative compromises her family and I devised to provide support for her while allowing her to maintain a measure of autonomy. I thought that if only I had known her for years and been able to establish a relationship with her, I could have chipped away at her denial. She might have trusted me and let me gradually arrange increases in the amount of supervision she had, allowing her to stay at home. Instead, she lost her zest for life after her daughter, at her wit’s end, placed her in a nursing home.

These health care virgins were the exceptions that proved the rule—almost all older people have a long history of interactions with the health care system, and most of those interactions take place in the doctor’s office. Even the outliers, like my patient who had stayed away from the medical profession for decades, sought help in the outpatient setting when they finally developed problems that either they or their families could no longer ignore. The doctor’s office, for the vast majority of patients, is where the journey through the health care maze begins. And the tour guide, the person most likely to accompany them through sickness and through health, is their personal physician.

At last count, Americans made over one billion office visits a year, slightly more than a quarter of those visits involving people over the age of sixty-five, although they account for only 12 percent of the population.1 And older people don’t just go to the physician once a year for a checkup: they make an average of seven visits to the doctor over the course of a year. Not only do they have many appointments, but they typically see more than one doctor. Fewer than half of their visits are to a primary care physician, with the remainder involving either a medical subspecialist—such as a cardiologist, hematologist, nephrologist or rheumatologist—or a surgeon.2

The office practice of medicine is a crucial component of medical care not just because of the sheer volume of visits, but also because it is the gateway to the rest of the health care system. It is in the office that most blood tests, x-rays, and other procedures are ordered. It is in the office that primary care physicians discover or elicit medical problems that lead to a subspecialty referral. It is in the outpatient setting that much of community-based, long-term care, such as visiting nurse services and physical therapy, is initiated. Typically, it’s the outpatient physician who directs patients to the hospital, and from there to the skilled nursing facility. And it’s in the office that the doctor-patient relationship is most often established and developed—the relationship that is at the heart of the patient’s experience of the health care system.

Over the years, I’ve seen patients in the hospital, in the skilled nursing facility, and in my consultative outpatient practice. Some of these patients arrived at my doorstep from solo or small group practices. Some got their care in a multispecialty group practice. But while the office practice of medicine looks very different depending on whether the practice is large or small, urban or rural, hospital-affiliated or free-standing, I’ve been struck by how many of its basic features are the same. This homogeneity reflects the interests of physicians, hospitals, government regulators, health insurers, and the drug and device industries that shape the essential characteristics of contemporary ambulatory care. These same interests determine what happens to the patient when he or she has an appointment. I came to appreciate just what “going to the doctor” means for older individuals not just through my own patients, but also thanks to my father-in-law.

Saul’s Story

The man usually dies first, but that’s not how life unfolded for my in-laws. After forty-four years of marriage, Ada succumbed to colon cancer. She died at home, with hospice services. And then Saul’s world fell apart.

Ada had been the family’s chief executive, as I’d learned when I first met my future in-laws. She and Saul had complemented each other perfectly. She was sociable, vivacious, and gregarious; he was one of the shyest men on the planet. She organized the couple’s social life, which mainly involved visiting her sisters and brothers and their families; he worked in their pharmacy six and a half days a week. She arranged things, from hiring an interior decorator when they first moved to a new apartment after they retired, to college visits when their son (my future husband) was a high school junior; and Saul handled the finances. She made the decisions, whether about getting a new car, which they did every ten years, or going on vacation, which they did with just about the same frequency; he was the family breadwinner. His life was his family and his drugstore.

For a year after Ada died, Saul stayed on in the Philadelphia high rise apartment complex where the couple had lived since Saul sold his struggling pharmacy. He managed, but barely, despite a housekeeper who came in weekly, then twice a week, and then daily. My husband began traveling to Philadelphia every couple of months to check on his father. He began worrying about his father after his first car accident, in which mercifully only the car was hurt. He worried more when he discovered his father wasn’t able to balance his checkbook and sometimes paid the same bill several times. Ultimately, he concluded that the status quo was no longer viable, and he persuaded his father first to give up driving and then to move into an assisted living facility in Boston, near us. Seventy years after arriving in the United States, a refugee from the Russian civil war and Ukrainian pogroms, Saul left Philadelphia.

Compared to the other disruptions associated with moving, starting over with a new physician was relatively minor. But Saul had gone to the same doctor for fifteen years. And before that, he hadn’t gone to a doctor at all. Only when he’d had emergency surgery for an abscess and was found to have very elevated blood pressure—which he’d probably had for some time, judging by the abnormalities on his electrocardiogram that indicated permanent heart damage—did he start seeing a primary care physician regularly.

I didn’t think that finding a new doctor would be difficult. Surely, only remote rural communities suffered chronic severe doctor shortages. And Saul had particularly good health insurance—in addition to Medicare Part A (hospital coverage) and Part B (physician and lab test coverage), he had supplementary coverage, the so-called “gap insurance” for co-pays and deductibles. Not only that, he didn’t have many medical problems apart from his high blood pressure, chronic constipation, and a little trouble with his memory: he’d be an easy patient. My assumption that it would be easy to find a new doctor couldn’t have been more wrong.

Access to Primary Care

After the passage of Medicare, resulting in health insurance coverage for virtually everyone over age sixty-five, access to primary care was in principle not an issue for older people in the United States.3 The reality has been a bit different. Some of the vaunted universal access is illusory if the patient lives in what is euphemistically called an “underserved area,” a region with an insufficient number of physicians to meet the demand. And some of that access is eroding as more and more physicians decide they will not accept any Medicare patients. Disappointed by the levels of reimbursement available from government insurers, particularly but not exclusively Medicaid (the combined federal-state program for the poor), 15 percent of self-employed physicians in a recent survey indicated they are not taking patients with either Medicare or Medicaid, and another 25 percent indicated they are undecided about what their policy will be in the coming year.4

A growing number of primary care physicians are shunning conventional practice models in favor of a “concierge practice.” In this arrangement, they either bill patients a “retainer”—usually many thousands of dollars a year, while not accepting payments from Medicare—or they charge a “membership fee” for various “extra” services on top of what they can bill Medicare for. These extras include round-the-clock physician telephone availability, same-day appointments, and longer, more leisurely visits. This structure allows physicians to have smaller patient panels—often considerably smaller.5 But these practices are not an option for poor patients, and they have the potential to further decrease access to primary care by creating a two-tier medical system.6 Currently, concierge practices are relatively rare but the number of such practices has been growing dramatically, with more and more practicing physicians saying that they are considering a transition to this model.7

On top of the defections to concierge medicine, the older patient has to contend with a shrinking pool of primary care doctors. By some estimates, the United States already had a shortage of primary care doctors in 2010, and by 2020 that deficit is projected to grow five-fold. In part, this is related to the lower salaries that generalists (internists, family physicians, and pediatricians) command compared to specialists: the average starting salary for a family physician is less than half that for a urologist.8 In addition, primary care doctors are retiring, cutting back their hours, or leaving the practice of medicine altogether.9 And they’re not being replaced by young new physicians at anything near a sufficient rate: a survey of doctors in internal medicine residency programs between 2009 and 2011 found that only one-fifth of them planned to become generalists; the remainder expected to specialize in a field such as cardiology, nephrology, or oncology.10 Recent surveys hint at a reversal of this trend, with growing numbers of medical school graduates opting for family medicine or primary care internal medicine residencies, but how many will remain committed to primary care rather than moving into administration, or leaving the field altogether, remains to be seen.11

First Steps

Saul had a great deal of adjusting to do after he moved to the Boston area. He still missed his wife terribly. He had to get used to waking up in a strange apartment and he had to learn to find his way around his new neighborhood. With more important things on his mind than medical care, he took a laissez-faire approach to finding a new physician. He did ask his fellow residents at the assisted living facility for suggestions, and one chatty woman at the dinner table recommended her own doctor, but that physician’s practice was full. Saul mentioned to the director of the assisted living facility that he was looking for a doctor and she provided a list of local physicians, but half of them had moved away and the other half weren’t taking new patients. After he’d lived in the Boston area for several months and still hadn’t found a doctor, I decided to intervene. As a physician who had lived and worked in the area for over twenty years, I felt confident that my connections would suffice. I was mistaken. Many phone calls and false leads later, a friend of a friend led me to Dr. Walker Wilson, an internist with a practice affiliated with a nearby community hospital. I didn’t know him personally, but I was told he was a good doctor.

Once I’d found a doctor for Saul, I figured the access problem had been solved. I’d forgotten, or maybe I never appreciated, how many steps remained before Saul would actually meet Dr. Walker Wilson—and how hard it would be for him to climb those steps. Even calling to make an appointment was a challenge. Saul wasn’t used to dealing with an “interactive voice response” program, which is what he encountered when he called to set up an appointment. It took him a while to realize he was speaking to a machine—he had grown up in an era when a real person always answered the phone. He became so flustered that he couldn’t remember whether he needed to press one (for prescription renewals), two (for an appointment), three (for a referral), or four (to speak to a human being). He finally managed to push the right button, only to be kept on hold for what seemed like eternity, and then, just when he thought surely he would be put through, the line was disconnected. But Saul was both patient and persistent, so after several tries over the course of a few days, he succeeded in making an appointment with Dr. Wilson.

Scheduling an appointment did not guarantee that Saul would end up at the right place at the right time. First he had to get to the doctor’s office. The office was in a low-rise building conveniently located down the street from a small community hospital. At least the arrangement was convenient for the doctors working in the building who could go back and forth between the hospital—where some of them saw patients or taught medical students—and their offices. For patients, it wasn’t quite so convenient. The building wasn’t near a bus or subway stop. And if Saul were still driving, which he wasn’t, he would have had to park in a narrow, winding garage with multiple levels that was a nightmare to navigate, and where the distance between the upper levels and the office itself was considerably longer than he could have managed.

Saul took the “Ride” from his assisted living residence to the doctor’s office building; he had given up driving and didn’t want to bother my husband and me. The van driver dropped him off in front of the building, leaving him to make his way to Dr. Wilson’s office. That strate...

Table of contents

• Cover
• Series Announcement Page
• Title Page
• Copyright
• Dedication
• Contents
• Prelude
• Abbreviations in the Text
• Part I: The Office
• Part II: The Hospital
• Part III: The Skilled Nursing Facility
• Finale
• Acknowledgments
• Notes
• Bibliography
• Index
• Series Page