Doctors were told to be blind to the cost of care [PODCAST]

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He counts four wounds in American medicine. Patients rarely bring up the first one, which is what health care costs. Narinder Singh Parhar is a physician with more than three decades in internal medicine, hospital medicine, and intensive care. This episode is based on his article “Health care affordability is now a moral crisis,” published on KevinMD. A retired Korean War veteran had Medicare, a supplemental plan, and a lifetime of work behind him. He still could not fill a $500 prescription near the end of the year. Narinder argues that spending has piled up in hospitals, imaging, procedures, and specialty care while primary care and the basic work of keeping people well go underfunded. He is blunt about the profession’s part in it, saying physicians were taught to be blind to what care costs. You will hear him walk through the ordinary decisions where that shows up: the generic, the office biopsy, the shoulder MRI. He closes with a take-home for physicians that starts somewhere unexpected, with their own health.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at kevinmd.com/podcast. Today, welcome back Narinder Singh Parhar. He’s a physician, and his KevinMD article is “Health care affordability is now a moral crisis.” Narinder, welcome back to the show.

Narinder Singh Parhar: Thanks, Kevin. Good to be with you.

Kevin Pho: All right. So tell us why you decided to share this particular article on KevinMD, and then talk about the article itself for those that didn’t get a chance to read it.

Narinder Singh Parhar: Well, Kevin, I have practiced medicine for nearly 40 years in primary care, hospital care, and intensive care medicine. In addition to the challenges of diagnosis and of proposing appropriate treatments, the affordability issue has come up again and again in my experience. Although I practiced in a fairly affluent area, even people who had worked all their lives and had good insurance continued to face the struggle, more and more, that they cannot afford to cover even their primary insurance or their secondary insurance. And then on top of that, the rising co-pays, the deductibles, et cetera, et cetera.

I think I shared a story in the article of one of my patients, who was a retired Korean War veteran. He was a very nice gentleman, hardworking, with his wife and his daughters supporting him. He had primary insurance, Medicare, and secondary insurance, and he was not in any way someone who had shirked his responsibility. But even at that level, he complained to me that he was having difficulty filling a prescription for a steroid long-acting bronchodilator at $500 a month, near the end of the year.

So that kind of shook me, and then I delved deeper into the issue and found that more and more people are affected by it. They don’t discuss it with their physicians and care providers, but this issue is one of the four grievous wounds that I consider to be affecting our health care model. The others are accessibility, polypharmacy, and microbial drug resistance. So that is how this article came about.

Kevin Pho: So in your article, you talk about affordability more as a moral issue rather than purely an economic one. Tell us why you framed it that way.

Narinder Singh Parhar: Well, I found that people who are good citizens, who have worked all their lives and have contributed to the system, are still being left behind. They are having to choose between the groceries and the prescription refills, the co-pays, and having the appropriate tests done, including, say, any imaging study or lab work, for the concern that it might not be covered.

So I find that something like this should not happen in a country like ours, where we are at the top of the world economy, but so many of our population is having to worry about their health and their economics at the same time. They don’t want to go bankrupt because of one single hospitalization, and I won’t blame them.

Kevin Pho: One of the things that you wrote about in your article was that the structure of our health care system contributes to this affordability crisis, right? You wrote that the system has gotten more top-heavy, more money spent on hospitals, imaging, procedures, and specialty care, and that’s leading to some of the situations that you saw in your patient who can’t even afford a steroid bronchodilator, right?

Narinder Singh Parhar: Yes. Well, in the article that we covered before and in my other publications, I have talked about strengthening the base and broadening the base of our health care, giving more responsibility to the patients by teaching them some basic health enhancement education, like, say, muscle preservation, joint preservation, balance restoration, proper sleep, proper nutrition, et cetera, and decreasing screen time, as well as involvement in some daily exercise, or at least four or five times a week. So that is as far as the patients are concerned.

For the physician community, I propose that as a health care model, we need to redirect our financial as well as our intellectual resources toward primary care. Primary care needs to be number one. They should be up to date on these basic health restoration areas like muscle preservation, joint preservation, balance restoration, as well as nutrition and sleep hygiene. So these are not minor issues. Sometimes we think that these are trivial, that they are not too fancy, and we just leave it to people to do on their own. So I think primary care needs to be more involved in that, and they need to be appropriately respected and reimbursed for these investments themselves. At this time, I think it is the opposite.

Kevin Pho: So we’ve talked about, of course, policy issues, and you talked about things patients can do more for themselves. Now, when you were practicing primary care in the exam room, give us some examples of some of the things that you did to help alleviate some of these affordability issues for your patients. Did it influence the treatments that you prescribed and the tests that you ordered?

Narinder Singh Parhar: It did. And I am very candid to share with you that our programs, our practices, are not very much tuned toward spending more physician time on preventive medicine. So I personally did, and many times I fell behind my schedule. Patients would love that I had spent 20 minutes, 30 minutes with them, listening to them, talking with them, and showing them myself some specific biomechanical positioning for them to correct. But that again, at the end of the day, the physician or the practice has to account for where the revenue is coming from. That is where I again come back to the policy that the reimbursement structure should also change.

Kevin Pho: Now, when it comes to the cost of care, did you spend time talking to patients in terms of what they can do to help better afford some of their medications, especially if you have this bronchodilator that’s costing $500? What can physicians do to help individually in the exam room, help patients navigate all the different options that they have when it comes to their medications?

Narinder Singh Parhar: Well, of course the topmost is staying healthy. Health enhancement. Some simple exercises, breathing exercises, yoga training, tai chi, weight control, and GERD control. All of these are tied together in what I call health enhancement. Naturally, if there is less reflux, the asthma exacerbation will be less. If the patient is exercising moderately, then the weight control will be helping the patient. Exercise will reduce the stress as well as improve the motivation. Again, motivation to do it again the next day.

So then, of course, avoiding certain stimulants which could be triggering, like, for example, some patients in my practice experienced that cold drinks, refrigerator drinks, and food exacerbated their asthma attacks. So something like that. And of course, being their own doctor as far as asthma is concerned, calling their doctor at the first instance when there are signs of decreasing respiratory efficiency.

Kevin Pho: What do you tell physicians who feel powerless, that the system can’t change? Because I know you talked about a lot of the things about paying and valuing primary care more, but I talk to a lot of primary care physicians who feel helpless in our system. What do you tell these physicians who want to make that difference, who want to make that moral argument to help with affordability, but they feel powerless to do anything? What can they do?

Narinder Singh Parhar: Well, one philosophical statement I would make is that in health care, nothing can go ahead without the consent and participation of the physician community, because we control health. Our policies have changed because we were incognizant of the cost of health care to begin with. We were told that we should be blind to the cost of care. I am afraid that that itself contributed to the rising costs of health care, where then what we called bill counters came in, because cost has to be controlled.

And physicians themselves have to take responsibility: Whatever tests I order, is there any alternative to it? Or what prescription do I have to order, the latest prescription for which even a generic is available? Or if there is a suspicious mole on the skin, do I really need to refer this patient to a dermatologist? Can I do a biopsy in the office and save the patient and the system so much running around? Or if there is a pain in the shoulder, do I need to order an MRI, or refer the patient to an orthopedist, just for the sake of convenience, or to go on and see the next patient? So all these things matter, and I think the physicians can do them.

The other message I have for the physician community is, number one, to take care of their health by, again, the things I talk about again and again: muscle preservation, joint preservation, good hygiene, good nutrition, daily exercise, and of course, stress management. Share that with their families. The happy physician will be a more productive physician, a more caring physician. And that physician will pass these habits and these practices on to their patients. So we would have a virtuous cycle going on.

Kevin Pho: We’re talking to Narinder Singh Parhar. He’s a primary care physician. Today’s KevinMD article is “Health care affordability is now a moral crisis.” Narinder, let’s end with your take-home messages that you want to leave with the KevinMD audience.

Narinder Singh Parhar: Well, I think one thing my audience needs to take home is that we, the caregivers, are individuals, we are humans. We do need to take care of ourselves, our health. That is extremely important. Then we need to take care of the health of our family, both physical, mental, and emotional. And of course, we need to be cognizant of the cost of health care. We are an important part of the health care team. We are rather the leaders of the team, so we need to take responsibility for controlling the health care cost while working toward providing the best of health care, both acute and chronic.

Kevin Pho: Narinder, thank you again for sharing your perspective and insight, and thanks again for coming back on the show.

Narinder Singh Parhar: Thanks, Kevin. Thank you. Good to talk to you.

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