Being a patient in today’s convoluted healthcare system can feel lonely and often infuriating. While it’s often hard to know who is responsible for that, recent headlines have revealed the healthcare system’s ugly underbelly: that sometimes those who say that they are here to help are more likely hindering.
From the Federal Trade Commission suing the 3 largest Pharmacy Benefit Managers (PBMs) over inflated drug costs, to Optum’s botched medical practice takeover in Middleton CT, to the ever-growing evidence of the hidden pitfalls of Medicare Advantage plans, the trend is growing. What these stories have in common is that in each case, a privately held company promised to deliver quality and affordable healthcare, while in fact doing the opposite and lining their own pockets along the way.
As a former physician, a two-time cancer survivor, and now a healthcare podcaster, I have had thousands of conversations over the years about the doctor-patient relationship and what helps and hurts it. Because of these recent headlines, patients might be wondering who we can trust to have our best interest in mind. Ironically, we are often pointing the finger in the wrong direction, towards the one person most likely to actually care about our wellbeing the most: our doctors. This isn’t surprising, as the doctor is the face of medical care, as opposed to the third-party entities lurking behind the curtain and pulling the strings like the Wizard in Oz. On the surface it likely appears that many of the challenges we face as patients - lack of affordability, long wait times, unavailable appointments, prior authorizations - are related to the person who we are directly experiencing them because of. But it is both naïve and, in most cases, factually incorrect that these challenges are caused by any action or decision made by our doctor.
Healthcare affordability is multifactorial and determined by insurance, drug pricing, access, and often inequities – almost none of which our doctors have control over. Long wait times may seem like they are caused by the doctor taking too long with other patients, or choosing to see too many patients in a day, or working too slowly. Though in most cases, our doctors show up to work and are told by someone else how many patients they have to see that day (usually too many), which then leads to them running late. It also means that they are sometimes being faced with the moral injury of having to decide whether they want to run on time for the day, or want to give each patient the time that they both need and deserve. Lack of available appointments are frequently caused by healthcare worker shortages, an aging population driving up demand, and institutions that prioritize bottom line over quality healthcare. Endless prior authorizations are required both for patient safety and cost control, but also are sometimes used to deny appropriate care. None of these are our doctors’ decisions.
An example of this is the private equity company that buys an outpatient clinic or a hospital and then forces unrealistic work quotas and schedules on staff to meet a desired bottom line. This causes doctors to run late, long waits for appointments and harried staff and doctors. Another example is PBMs that are setting drug costs for health insurance companies. When our doctor prescribes a medication that is too expensive for us, a common assumption is that the doctor should’ve known not to prescribe that drug or perhaps doesn’t care about our wallet. But the reality is that it’s often out of their hands.
One doctor might see 20-40 patients a day depending on their specialty, with each patient having different health insurances, plans and formularies. There is no way that a doctor could possibly keep all of that straight, nor should we want them to. We should want our doctors spending every possible minute focusing on delivering hands-on healthcare. That price-setting almost certainly was the result of decisions made by our health insurance company’s contracted PBM. In these cases, who benefits financially or otherwise the most from these arrangements? Not the frustrated patients or the overworked doctors, but the companies themselves: PBMs are making record profits while we are left paying the high prices for the drugs.
To be sure, there are doctors whose choices affect their patients’ experiences negatively. There are greedy doctors, slow doctors, impersonal doctors, and just not-great doctors. But if we are unfortunate enough to be seeing one of them, at least we might have the option to switch to a different one. We have no option though, to escape the PBMs and health insurance companies that are prioritizing bottom lines and bonuses over our healthcare.
Who then will be my partner in making my healthcare as effective, productive and fulfilling as possible? Certainly not the entities mentioned above. Since an overhaul to our healthcare system is likely far in the future, for now I recommend leaning into the parts of our healthcare that we can control: our relationship with our doctors, which for many is non-existent or lacking. This will likely involve some relationship-building techniques like letting them know how important our relationship with them is, showing them empathy (ask about their day!), listening and following their advice to show our trust in them, expressing our appreciation, respecting boundaries and communicating openly and honestly. Putting our efforts into building these relationships makes sense. After all, our doctor is likely the one person actually looking out for our health.