A Doctor’s Declaration of Independence

Opinion – Wall Street Journal

It’s time to defy health-care mandates issued by bureaucrats not in the healing profession.

By Daniel F. Craviotto Jr.

April 28, 2014

In my 23 years as a practicing physician, I’ve learned that the only thing that matters is the doctor-patient relationship. How we interact and treat our patients is the practice of medicine. I acknowledge that there is a problem with the rising cost of health care, but there is also a problem when the individual physician in the trenches does not have a voice in the debate and is being told what to do and how to do it.

As a group, the nearly 880,000 licensed physicians in the U.S. are, for the most part, well-intentioned. We strive to do our best even while we sometimes contend with unrealistic expectations. The demands are great, and many of our families pay a huge price for our not being around. We do the things we do because it is right and our patients expect us to.

So when do we say damn the mandates and requirements from bureaucrats who are not in the healing profession? When do we stand up and say we are not going to take it any more?

The Centers for Medicare and Medicaid Services dictates that we must use an electronic health record (EHR) or be penalized with lower reimbursements in the future. There are “meaningful use” criteria whereby the Centers for Medicare and Medicaid Services tells us as physicians what we need to include in the electronic health record or we will not be subsidized the cost of converting to the electronic system and we will be penalized by lower reimbursements. Across the country, doctors waste precious time filling in unnecessary electronic-record fields just to satisfy a regulatory measure. I personally spend two hours a day dictating and documenting electronic health records just so I can be paid and not face a government audit. Is that the best use of time for a highly trained surgical specialist?

This is not a unique complaint. A study commissioned by the American Medical Association last year and conducted by the RAND Corp. found that “Poor EHR usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information between EHR products, and degradation of clinical documentation were prominent sources of professional dissatisfaction.”

In addition to the burden of mandated electronic-record entry, doctors also face board recertification in the various medical specialties that has become time-consuming, expensive, imposing and a convenient method for our specialty societies and boards to make money.

Meanwhile, our Medicare and Medicaid reimbursements have significantly declined, let alone kept up with inflation. In orthopedic surgery, for example, Medicare reimbursement for a total knee replacement decreased by about 68% between 1992 and 2010, based on the value of 1992 dollars. How can this be? Don’t doctors have control over what they charge for their services? For the most part, no. Our medical documentation is pored over and insurers and government then determine the appropriate level of reimbursement.

I don’t know about other physicians but I am tired—tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way I practice medicine. No other profession would put up with this kind of scrutiny and coercion from outside forces. The legal profession would not. The labor unions would not. We as physicians continue to plod along and take care of our patients while those on the outside continue to intrude and interfere with the practice of medicine.

We could change the paradigm. We could as a group elect not to take any insurance, not to accept Medicare—many doctors are already taking these steps—and not to roll over time and time again. We have let nearly everyone trespass on the practice of medicine. Are we better for it? Has it improved quality? Do we have more of a voice at the table or less? Are we as physicians happier or more disgruntled then two years ago? Five years ago? Ten years ago?

At 58, I’ll likely be retired in 10 years along with most physicians of my generation. Once we’re gone, who will speak up for our profession and the individual physician in the trenches? The politicians? Our medical societies? Our hospital administrators? I think not. Now is the time for physicians to say enough is enough.

Dr. Craviotto is an orthopedic surgeon in Santa Barbara, Calif., and a fellow of the American Academy of Orthopedic Surgeons.

Letters – Wall Street Journal

Prescription for M.D.s: Unity and Their Own Lobbyists?

Physicians have no voice, and cannot unionize like others to protect our incomes, and cannot bill by the minute like lawyers with no oversight or checks and balances.

May 6, 2014 3:46 p.m. ET

Bravo to Dr. Daniel F. Craviotto Jr. for “A Doctor’s Declaration of Independence” (op-ed, April 29). Like him I have witnessed the gradual erosion of the practice of medicine over my last 40 years as a physician. We are the only profession where our workload consistently goes up while our incomes go down predictably every year, slashed whimsically by the government and insurers for the simple reason that they can.

We physicians have no voice and cannot unionize like others to protect our incomes, and we cannot bill by the minute like lawyers with no oversight or checks and balances. Countless hours of phone calls, chart reviews, curbside consults to help another doctor and reviewing films are not reimbursed; they are done as good will. And to add insult to injury we spend 10 to 15 years learning our trade, get held to impossible standards of perfection, are vulnerable to being sued daily by a corrupt and unregulated legal system, then forced to conform to an electronic billing system that adds hours to our day. If patients knew how we get paid, they would rally to defend their doctors and not vote for corrupt politicians who brainwash the public into thinking we are overpaid, and thus deserving of cuts.

We did surveys many years ago asking patients how much their doctor was paid for a coronary angioplasty and, no surprise to us, they had no clue and were uncomfortable even thinking about it. The average guess was $10,000 per procedure, when the real number was $900 then (now $600). Even today a heart surgeon is paid only $900 for open-heart bypass surgery no matter how many hours he spends in the operating room, how long it takes to see the patient before the procedure or the five to seven days afterward required to take care of them.

The public needs to get educated and involved in its health care, as we are all in it together. Doctors are fleeing their practices in record numbers and there will be fewer of them to take care of a growing number of patients. You can do the math and realize the quality of care and access will go down as doctors spend more time filling out forms than seeing patients.

Richard A Schatz, M.D.

San Diego

Dr. Craviotto has learned that the only thing that matters is the doctor-patient relationship. However, everyone else seems to have learned that other things matter more. Patients have learned that the only thing that matters is how much they have to pay out of pocket for their health care—the less the better. Toward the end of my private practice, patients even resented paying their co-pay (which was usually much less than the tip they left for their waiter at a restaurant), and they really didn’t care how much, or even if, the doctor was paid, because they had been removed from the cost equation. They didn’t care about a relationship or the fact that their primary-care physician referred them to a trusted colleague, only about whether I was in the network.

They learned that health care is a commodity, evidently quite inelastic regarding out-of-pocket cost. Dr. Craviotto’s colleagues have learned that the practice of medicine has changed from an art to a business, with winners who align themselves with the payers and device companies, and losers, who don’t.

The insurance industry and federal government have learned that once you’ve gone through college, medical school, a fellowship and you have a family, mortgage and education loans to support, you’ll comply with any regulation, work any shift and accept any compensation, because what else can you do?

Those of us (including Dr. Craviotto) who were lucky enough to practice during the time when the only thing that did matter was the doctor-patient relationship will always have those memories to cherish. I’m truly sorry that today’s physicians will never have that experience.

John P. Siegel, M.D., MBA

San Jose, Calif.

For med students and recent grads it’s like being in shackles because never before have so many owed so much with the prospect of earning so little.

David J. Gross, M.D.

St. Augustine, Fla.

Go talk to someone trying to work in the banking industry, the refining industry or for the airlines. The issue of increased regulation and imposition by the regulator is not new. Where are your lobbyists? Why aren’t they backing candidates that say we have too much regulation?

A. E. Steigelman

Camarillo, Calif.