I recently read The Nordic Theory of Everything and was
amazed and heartened by what the author, Anu Partanen, revealed about the
Nordic and American systems. More importantly, her theories resonated with my
own experiences in medical practice.
Partanen’s
perspective, backed by several annotated and well documented studies, is that
when populations in the Nordic countries pay taxes, and a streamlined
government administers those taxes into healthcare, disability, retirement, and
primary, secondary and tertiary education – for everyone – the population then has, in fact, more independence and more
freedom. People aren’t tied to jobs because of the need for health insurance;
parents don’t mortgage their houses to pay for their children’s education;
people don’t go into hock and get stressed out when they have to pay and care
for their aging parents; and school quality isn’t dictated by the neighborhood
where people live. When these core needs are taken care of, people are free to
base their relationships on what Partanen terms “the Nordic theory love”, and
not on dependency and obligation.
And, by the time you
figure the American out of pocket costs for healthcare, tuition, disability
etc. etc. added to the taxes paid, the amount Nordic populations pay in taxes
to pay for every one of these services is quite comparable – and equitable.
That sounds pretty intelligent to me.
With respect to
healthcare, it’s universal and uniform, and therefore the administration costs
are streamlined. There is no privatization, no advertising, no competition, and
no convoluted calculations for what’s covered and what isn’t.
I wrote about my
experience as a physician with the misdirected explosive growth of
administrative complexity in my memoir Lonely
Refugee. Here is an excerpt:
When I began to
work at Group Health [in 1984] there were no treatment record forms (TRFs) or
billing forms to fill out. All I had to do was see patients and write good
chart notes – good by peer review standards. My practice kept me jumping for
sure, especially on days that I saw up to thirty patients in eight hours, but I
spent most of my time coordinating patient care and leaving clear tracks in the
charts. Back then there were no copays, no deductibles, no exclusions that
patients were obligated to cover. All patients paid for were their monthly
dues. That is all they paid for! And there was pretty much one single coverage
plan – no deluge of coverage options from which to choose, and through which to
navigate. One basic healthcare plan served practically all. At the time, I
didn’t realize how lucky I was.
Twenty years
later, myriad levels of administrative complexity had seeped into my practice.
I had treatment record forms I had to fill out to document the level of care I
provided, and to account for every procedure I performed, from paring corns to
performing endometrial biopsies and suturing lacerations. A plethora of billing
codes for every possible diagnosis and procedure inundated my work life. I
could only charge higher diagnostic billing code levels if I followed the
required documentation guidelines. I had to write my clinic notes in minute
detail, using the exact mandated language. If I failed to follow the strict
rules, I risked Medicare fraud charges: billing for work there was no evidence
for in the chart . . .
Hundreds of
administrative non-patient care positions and system “upgrades” surfaced to
cope with the tsunami brought about by the new changes. I was astonished at the
magnitude of the upheavals: clinics were remodeled to create registration areas
where newly hired clerks collected copays and determined insurance coverage;
business departments exploded with coding technicians, billing clerks, and
computer programmers; huge infrastructures materialized to develop, monitor,
update, and maximize data capture and optimize reimbursements. And to keep up
with and compete with the nationwide healthcare chaos, Group Health expanded
its insurance coverage options and now offered literally hundreds of plans – so
confusing, that I no longer knew how or whether the tests, medications,
referrals, and procedures I ordered would be paid for by my patient’s coverage
plan.
When patients
asked me, “Is that lab test covered, doc?” I could only shake my head. “I don’t
know. You’ll have to check at the business office.” . . .
Patients would
then have to decide what they could pay for and what they couldn’t afford. I
had to let them know the risks of not getting the tests done, or I had to
scramble to find less expensive care options. All this required extra time, and
inconvenienced both my patients and me. Care was occasionally compromised when
patients didn’t check back after heading to the business office, or if they
waited until they could come up with funds to pay for the medications and tests
that I ordered. Many times patients became disgruntled with the costs they had
to bear, and some became irate when the drugs or tests to treat their
particular illness weren’t covered. I resented having to spend more of my
clinic time documenting widgets of care and acting as the gatekeeper and
mediator with my patients.
I was sickened to
see how, with all the new changes, the focus had shifted away from patient
care. Our medical staff meetings that once provided educational case reviews
and clinical lectures, were now replaced by coding and charting classes to
train providers on how to comply with the Medicare standards and maximize
reimbursements from the government and insurance companies. The coding
specialist frequently showed up at our meetings, giving us the latest code
changes. For diabetes alone, hundreds of coding options were created – and they
were updated almost weekly. The administrators had to make sure that we were
entering the newest and most complete classifications. Learning these codes,
taking the time to make sure all the parameters needed for the appropriate
level of service were included in my charting, keeping up with the frequent
updates and “corrections,” consumed more and more of my time. It drove me nuts.
When the codes
were first introduced, the office billing clerks corrected the ones that I had
flubbed and added codes that I couldn’t figure out. These employees were
godsends! But when electronic charting was initiated, my backup system went
poof! I had to enter every darn diagnostic code myself. To my chagrin, the
computer wouldn’t allow me to order any labs, prescriptions, X-rays,
treatments, or referrals unless I entered the exact diagnostic code.
Many a time I
would flounder when with a patient. “Just a moment, Mrs. Smith. I’ll have to go
find the right code number so I can order your X-ray . . . I’m so sorry for the
delay, Mrs. Smith. Let me quickly finish up here and get you on your way.” But
by now, I would be ten or fifteen minutes farther behind in my schedule.
“Crap,” I would think to myself. “I’m going to be here until all hours
tonight!”
I didn’t question
that the electronic charting system improved access to medical records and
therefore served patients and clinicians well. What I was at odds with was how
most of us docs were staying at least an hour or two later to finish up with
our charting and paper work. I had to ask myself if the high complexity level
of billing, coding, coverage, and reimbursement systems also served to create
better health, and I knew the answer to that – I didn’t think it did! And that
made my extra work harder to accept. My disillusionment with the medical system
grew.
What do you think?
I highly recommend The Nordic Theory of Everything, and I dearly
hope that the U.S. will come to its senses and institute more effective and
efficient medical care – and education – and retirement – and disability –
coverage.
