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The US corporate medical machine is quietly crashing.

Doctors are leaving. There are articles all over about physician burnout, which is ludicrous. If the average family practice doctor works 60-70 hours a week, how much do you think mindfulness is going to help? And the crash is accelerating. I used to get about one prior authorization demand from an insurance company for a medication about every 2 weeks. Now I am getting 5-10 per week. Remember that I have chosen to work 40 hours a week which means that I see half the number of patients of a mainstream family physician. They are seeing 16-18-25 per day. My clinic is half over age 65, so mine may be on more medications than a clinic with a younger demographic. But... the entire country average age is climbing, the baby boomers like a swallowed goat, slowly diminishing in size as it moves through the python of years.

Each prior authorization either requires a time consuming phone call to the insurance company, one of the 800 companies, or is it 1300? I forget. Or it requires a separate log on to each insurance company with each having a different website, multiple different plans, everything arranged in different ways and places. I have a bit of trouble learning 800 websites. My bad, right? I could drop all insurance except medicare. Then I would have the medicare primary, Noridian, that handles 80% of the allowed bill and then multiple different secondary insurances and then patients have a "part D", a third insurance that covers their medications. Only mostly it doesn't cover them or covers less and less. Medications that a person has been on for 25 years, the insurance company suddenly decides that they no longer cover it. Or the copay goes from $30 to $260 per month. Or the medicine is no longer made. Or the secondary says the medicine is covered and the part D says it isn't. No, really, I am not making this up.

My receptionist is noticing too. "We saw less people this week, but the paperwork is piled higher." I think of it as deeper. I have a week of vacation coming and I am trying to clear out as much as possible. It is running on a treadmill that no matter how fast or well you run, each day it goes faster and each day the slope is steeper, until you want to lie down and let it dump you on the ground.

An elderly patient calls outraged because he has a bill. We check: medicare Noridian has a yearly deductible. His particular secondary insurance does not pay the deductible. "But it did last year!" says our patient. Yes, well. Don't we all read the entire policy yearly? Isn't it written in simple language so anyone can understand it? Don't the insurance companies put our health first and profit second?

The breakdown is accelerating now. I can't get notes from the specialists. Perhaps it the note is not done. I reviewed a specialist note with a patient yesterday: the specialist is the state expert and his note has three major errors about her care. One is an incorrect medication dose, one is that she has not tried a medicine that in fact she tried, and well, I forget the third. "That's wrong." she says. "Yeah," I say, "I am sorry. I could write to him but no one has time to correct the notes anyhow."

I try to get a note on another patient and the patient says that that particular specialist seems really tired and his office is a disorganized mess. It must be, since we've requested his consult note three times in the last two months without getting the note. He's the only one of his specialty on the Olympic Peninsula, 450,000 people. When he calls me back, it's always after 7 and he's always still at the office. "Why are you still at work?" I ask, "Can't you go home?" He laughs.

The trajectory is clear, as if a train has come over a mountain and started down, accelerating. The brakeman knows the brakes are gone and the curves are near the bottom. He thinks about derailment but the train is going too fast for him to get off. He wishes he had quit last week. Now all he can do is say a silent farewell to his family and those he loves, as the train hurtles through the quiet dark.

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