Health reform needs to end fee for service medicine

by Pearl Korn

As the health reform debate rages on, the central issue of how to improve care while reducing costs remains unaddressed.

Fee-for-service has reduced doctors to assembly line pieceworkers, paid by the office visit and procedure rather than by effectiveness of treatment. The result is an inefficient, costly and dangerous system. It is not unusual for a five minute office visit, which excludes clinical examination or note taking. Many patients/consumers can be seen in an hour. Time is money. And let us not forget those insidious, endless co-pays. The perfect storm is gathering as health care costs are now 17.3% of the GDP and rising.

Doctors and patients once had a close, almost familial, relationship lasting decades; a relationship seen in the success of the Veterans Administration, whose doctors are salaried. Today, seeing a doctor is short and impersonal as we shuttle from one “provider” to the next. How can this approach serve a patient better than a doctor engaging in dialogue and a thorough clinical examination?

I recently experienced how fee-for-service “healthcare” works up close, and I would like to share my own experiences here.

Two years ago I fell down stairs and was whisked off to a major New York hospital. I was seen by an ER doctor, not an orthopedist, which the injury clearly warranted. X-rays were taken, I was given a soft leg brace and a cane and discharged. The $35 cab ride home was the first of many costs to follow.

The following week I saw an orthopedist recommended by the hospital — one of only two names offered, the other being their Chief of Orthopedics. A father and son duo. The young doctor briefly touched my leg, announced that I had torn a calf muscle and would be fine in six weeks. His specialty knee replacement, and since I didn’t need a knee replacement, I was dismissed in under ten minutes with no follow up visit recommended.

Needless to say, I was not fine in six weeks. I saw another orthopedist who took X-rays, administered a cortisone shot and prescribed physical therapy at an office he owned, without an examination of the injured leg. At my next visit, I insisted on an MRI, and the doctor was surprised to find I had a torn ACL and meniscus; he thought I had simply a small knee tear.

During my visits, this doctor would simultaneously see five patients and was constantly interrupted. Back and forth he went, and I marveled how he could even remember each person’s issues.

It was now time for orthopedist number three. This doctor prescribed additional physical therapy and recommended I see a physiatrist at her hospital’s spine institute, thinking my leg problems were caused by my back. She couldn’t understand my continued difficulty walking after so many months.

The physiatrist was seen, two MRI’s of the back and cervical spine taken and a cortisone shot arranged, without any warning of its dangers (osteoporosis and stress fractures) or its 50% failure rate. The physiatrist diagnosed two herniated discs, which I did not have, then suggested another cortisone shot higher up in my back. The MRIs showed stenosis of the spine suspected as the root of my problem walking.

The hospital was paid $3,200 for the cortisone shot. A puncture of the skin, an injection is considered surgery and paid accordingly. I refused to pay a $100 deductible, instead expressing my displeasure at my treatment in a letter to the president of the hospital. So far, no response.

Since then, I have seen a spinal neurosurgeon who recommended two back surgeries, though I had no back pain. The first surgery has a 20% failure rate; the second surgery would fuse discs and add a rod to my back. No explanation was given as to why a second surgery was a possibility.

I have also seen three neurologists and was administered a $1,500 EMG test with no negative results, and have also been misdiagnosed with herniated discs, carpal tunnel and a pinched nerve in the neck; all nonexistent. Then there were 30 physical therapy sessions on my injured leg and 7 traction sessions on my back, at which my neurosurgeon laughed. I am reminded of snake oil salesman of another era.

This endless journey has delivered poor results at great physical, emotional and financial costs. I am convinced that fee-for-service and doctors’ defensive medical practices must be addressed in reform, along with medical malpractice. We can learn a great deal by looking at the national health care systems of many leading industrial nations, particularly how they pay doctors and why medical malpractice is a non-issue. These nations provide better health at half the cost.

Meanwhile, I continue to search for answers while my patience, resolve and check book wear thin. In the mean time, last week I saw the neurosurgeon again and after stating my back was not in pain for the third time, he announced that no back surgery was warranted.

He finally heard me. Yet, I am walking with a cane.

Pearl Korn is an advocate of improved Medicare for All, the United States National Health Care Act (H.R. 676).