Before I can go further, I think it is imperative that we discuss the issue of Physician ethics and professionalism. I have read much lately about these specific topics, and I believe the public is confused. Indeed, even I have been confused at times with some of the very persuasive arguments I hear and read, many of them by doctors. Funny that such an ancient bond between the healer and the patient, has become so complex in these modern times. And then I pause and think to myself, if me or someone I loved were very, very sick, and depending on my doctors for the best advice, would it really be so complex? No I don't think so. In fact it would be crystal clear what really matters.
What is professionalism? Each profession or trade has a different ethical goal, and it will adopt or embrace certain virtues to achieve that ethical goal. The essential virtues are honesty, integrity and objectivity. In medicine, the goal always is the good of the patient. The primary virtue is trust.
As physicians, we cannot ethically accept limits of any kind on our judgments regarding patient care. Physicians are required to reject any scheme, however well-meaning, that comes between them and their patients. This means we can allow no third party to come between the patient and the physician, including third party payers. Such schemes are defended as necessary for the "good of society," and that may be the case, and physicians can get swept up in this argument. But because the good of the patient is the highest goal in medicine, the "good of society" cannot be the physicians' primary goal.
Again, this can be complex when you try to think it all through, but back up and put yourself in the position of a seriously sick patient. What does the "good of society" mean to you when you think about your child lying on the bed with an appendix about to burst. Nothing matters but getting that child to the operating room for surgery. And you expect your surgeon to be as single minded as you. Anything less, would be a breach of medical ethics.
This basic principal, is a validation of ancient Hippocratic ethics which have not changed at all in the modern practice of medicine. If anything, this "highest ethic" in medicine, is more applicable than ever as third party interference is ever present, and must be resisted, even if it means the physician is at risk of being fired, kicked out of a preferred provider panel, being economically de-credentialed from hospital staff, losing his referral base, or just plain being pressured to get out of town. And don't think this doesn't happen every day to one of the remaining doctors that hasn't sold-out to the suits.
This is why it is so important to know "who owns your doctor."
(Note: I have borrowed liberally from the comments of Jerome Arnett Jr., M.D, in this section)
Friday, March 21, 2008
Sunday, March 16, 2008
So why do patients need to know this?
In the last four postings, I have tried to give the patient an inside look, at a face of medicine, which some health care corporations do not want you to see. As a quick review, I will summarize the highlights.
Health care is big business, over $2.7 trillion per year, and most of it takes your doctor's signature to make it happen. Because of this relationship, the medical industrial complex will do whatever it can do "legally" to control your doctor. If they control your doctor, they control the money.
Most states have specific laws against the corporate practice of medicine. The States of California, Texas, Colorado, Iowa and Ohio, have specific laws forbidding the employment of physicians by hospital/insurance companies. Why the rest do not, is a mystery to me. To circumvent those laws, big business must use every bit of leverage it can, to exert its considerable influence over your doctor, to further its financial gain.
Depending on the specific type of business arrangement your doctor has, in his particular practice, health care corporations that do not have your best interest as a patient in mind, may be able to exert considerable influence over your doctor's recommendations for any treatment you might need. This will be most apparent if you have an expensive illness like cancer or heart disease.
With the continued consolidation of health care, many doctors have found themselves in practice situations, in which they can be summarily relieved of duty, if they do not do as they are told. These doctor-as-employee positions are often very attractive, and may pay much more than positions that are doctor owned and governed. The trade-off is that the doctor who takes such a position has essentially sold-out. It may have been well meaning, and they may not even know they have done it because they have not been "leaned-on" yet. But soon enough they will find out, when the health care bubble bursts. And believe me that is coming.
Doctors whom have "not" sold-out, are proud of this, and also are happy to tell you so. Doctors that have sold-out, will be careful to avoid the question, and will be evasive with their answer.
It can very difficult to tell if your doctor is in the type of practice that does, or does not protect the physician-patient relationship. Most patients are oblivious to this important point. You want a doctor that works for you, with as little interference from the outside corporate world, as possible.
Doctors should get paid for what they do for you, not what they do for their employer. If your doctor is getting paid more than is justified by his productivity and time, on behalf of patient care, then he isn't really working for you any longer, he is working for his boss, whomever that might be.
That basically sums it all up. So now I ask you, is this really important to you as a patient? Does all of this matter? Well if you believe that your relationship with your doctor is important to your health and well-being, then you should be very concerned about the level of corporate influence over him, and as a result, you too. Your life could depend on it.
So how does one figure out if his doctor or doctors are no longer free thinking professionals, or rather just obedient employees doing as they are told for some nameless, faceless bureaucracy. That truly is the problem. There is no way to tell usually. You have to do some serious sleuthing. As I said, you can ask your doctor, but he may not be very forthcoming. He might try to hide it by misleading you. He might just flat out deny it. But the reality is, your doctor can get into all kinds of trouble for treating you improperly, or improper billing or disclosure of confidential information, but he is under no obligation to tell you the truth about who he really works for. There is no sanction I know of, under any State Medical Board, that says he has to tell his patients that he has traded the sanctity of the physician-patient relationship for a better or more convenient paycheck. Sorry, you are on your own.
Then again, maybe not?
Health care is big business, over $2.7 trillion per year, and most of it takes your doctor's signature to make it happen. Because of this relationship, the medical industrial complex will do whatever it can do "legally" to control your doctor. If they control your doctor, they control the money.
Most states have specific laws against the corporate practice of medicine. The States of California, Texas, Colorado, Iowa and Ohio, have specific laws forbidding the employment of physicians by hospital/insurance companies. Why the rest do not, is a mystery to me. To circumvent those laws, big business must use every bit of leverage it can, to exert its considerable influence over your doctor, to further its financial gain.
Depending on the specific type of business arrangement your doctor has, in his particular practice, health care corporations that do not have your best interest as a patient in mind, may be able to exert considerable influence over your doctor's recommendations for any treatment you might need. This will be most apparent if you have an expensive illness like cancer or heart disease.
With the continued consolidation of health care, many doctors have found themselves in practice situations, in which they can be summarily relieved of duty, if they do not do as they are told. These doctor-as-employee positions are often very attractive, and may pay much more than positions that are doctor owned and governed. The trade-off is that the doctor who takes such a position has essentially sold-out. It may have been well meaning, and they may not even know they have done it because they have not been "leaned-on" yet. But soon enough they will find out, when the health care bubble bursts. And believe me that is coming.
Doctors whom have "not" sold-out, are proud of this, and also are happy to tell you so. Doctors that have sold-out, will be careful to avoid the question, and will be evasive with their answer.
It can very difficult to tell if your doctor is in the type of practice that does, or does not protect the physician-patient relationship. Most patients are oblivious to this important point. You want a doctor that works for you, with as little interference from the outside corporate world, as possible.
Doctors should get paid for what they do for you, not what they do for their employer. If your doctor is getting paid more than is justified by his productivity and time, on behalf of patient care, then he isn't really working for you any longer, he is working for his boss, whomever that might be.
That basically sums it all up. So now I ask you, is this really important to you as a patient? Does all of this matter? Well if you believe that your relationship with your doctor is important to your health and well-being, then you should be very concerned about the level of corporate influence over him, and as a result, you too. Your life could depend on it.
So how does one figure out if his doctor or doctors are no longer free thinking professionals, or rather just obedient employees doing as they are told for some nameless, faceless bureaucracy. That truly is the problem. There is no way to tell usually. You have to do some serious sleuthing. As I said, you can ask your doctor, but he may not be very forthcoming. He might try to hide it by misleading you. He might just flat out deny it. But the reality is, your doctor can get into all kinds of trouble for treating you improperly, or improper billing or disclosure of confidential information, but he is under no obligation to tell you the truth about who he really works for. There is no sanction I know of, under any State Medical Board, that says he has to tell his patients that he has traded the sanctity of the physician-patient relationship for a better or more convenient paycheck. Sorry, you are on your own.
Then again, maybe not?
Saturday, March 8, 2008
On selling-out the physician patient relationship.
Some doctors are selling out the physician patient relationship to the highest bidder. That is a strong statement, but it is sadly true. To understand what it means to sell-out, you first have to know how it is that doctors get paid. This is very complex, and I will try to make it as simple as possible, but believe me when I say that the rules by which doctors get paid for what they do, are of a complexity that would make the I.R.S blush. It doesn't have to be that way, and it wasn't the doctors themselves that dreamed this up, but it has evolved over the years into the monster that it is, again, much like the I.R.S..
Most doctors get paid according to a set of rules known as C.P.T. coding. Almost everything that gets done in medicine has a code for the service provided. This "payment code," or "billing code" as it is more commonly known, is then generally linked to the patient by a Diagnosis Code, also known as an I.C.D. 9 code. That way, if a patient has the diagnosis of "appendicitis," it matches with the billing code submitted by the surgeon for "appendectomy."
There are vast books of diagnosis codes, and even larger more complex books filled with billing codes. How they apply in each and every conceivable patient care situation, creates almost limitless possibilities. Every type of provider you can think of, has their various codes for what they do. Every type of facility for providing services to patients has its billing codes as well. Are you starting to see what I mean when I say it is extremely complex? Doctors take classes frequently, just to keep up on the changes that occur most every year when a big group of government officials gets together and decides how much each service will be paid. Then it all gets posted in an official book called the "Federal Register."
Doctors don't bill in actual dollars when they perform a service. For billing purposes, everything we do has a "unit value." The units are referred to as "Physician Work Units." So for example, if you see your regular doctor for a typical 15 minute visit, he will submit a billing form with your diagnosis for that visit, and a billing code for what he did. This type of service is the most frequently rendered around the country, day in and day out, and is called an Evaluation and Management service. This particular example would render that doctor about "One Physician Work Unit." If he also performed a procedure, he would submit a code for that procedure in addition. An example would be a visit to the doctor to have your blood pressure checked, and a mole on your arm looked strange, so the doctor decides to do a skin biopsy at the same time.
Now how many work units are allowed for various procedures and visits, is extremely controversial and is a constantly undergoing revision as I had indicated. What is truly amazing is that the system works fairly well, for the most part. In general, the work units allowed for the various services rendered, are probably about as fair as it can be, given the politics of the Federal Government and the representatives of the various specialties. Many different variables are considered when assigning values to procedures. Some of these variables include the time it would be expected to take to do the procedure, the degree of extra specialty training required to do the procedure, the amount of post operative care that will be required of the doctor after the procedure which is generally included in the "surgical package," and the risk of malpractice that goes along with performing such a procedure. That is why a skin biopsy done in the office may render one work unit, and the removal of a brain tumor in the hospital, might be worth 40 work units.
Right about now, you are probably wondering, "what is a work unit worth in actual dollars?" That is a very good question. I will tell you that when a physician submits a bill, he actually gets paid according to a more comprehensive type of unit, called a R.V.U. or "relative value unit." This type of unit is actually a combination of the physician work units, the cost of facilities, and the cost of malpractice. If you look at any code in the Federal Register, it will give you the breakdown of each of the three components for that code, as a percentage of the total reimbursement allowed.
So again you ask, what does my doctor get paid for that 15 minute office visit? The answer is, "it depends". It depends on who is paying. Welfare/Medicaid pays about $28. Medicare pays about $37. Commercial insurers pay all over the map, but 150% to 200% of the Medicare rate is typical. These estimates are going to be very close, but not exact, because where you practice can affect reimbursement to some degree. Medicare doesn't vary much at all. That $37 give or take a buck, is going to be it, no matter where you practice. Welfare/Medicaid can vary widely depending on the state, and commercial insurance like most of us have, can pay all over the map, depending on how they can or cannot leverage doctors in that specific market. Lastly, let's not forget that most doctors get paid nothing for about 5% of the patients they see. So if you added up all of the R.V.U.'s, and all of the money collected, my guess is that it would probably be about $60 per R.V.U. on average,
Most doctors, by definition, are going to produce work units at around the median for their specialty. Surgeons and procedurally based specialists will produce more work units over the course of a year, than doctors who don't do a lot of procedures. Looking at the work unit data on thousands of doctors, all over the country in all of the various specialties, has found this to be true. So if you look at these doctors in their various specialties, and you take the median producers in each, you can get a data set that describes about how much that doctor will make, based on specialty. These data are widely available, but are generally proprietary in nature. One of the better data sets is called M.G.M.A., or Medical Group Management Association. There are others as well. And when you distill it all down, you can generally say that non-surgeon/non-procedure doctors are going to make about $150 to $200K, plus benefits, after expenses but before taxes, functioning at the median. The surgeons are going to do about $75 to $100K more. Surgeons train longer, by 2 years or more on average, and they work about 10 hours per week more on average, and they take more intense and more frequent after hours call, on average. That is why they produce proportionally more work units than non-surgeons. A very simple way to add it up, is to say that non-specialitst doctors make about $100 per hour, and specialist doctors make about $150 per hour. To both I would add about $20-$25 per hour in benefits.
So now you have a great insight into the financial world of doctors, complex as it may be. But you already know that they go to school and training for a ridiculously long time and take on all of that student loan debt, they work very hard long hours, and they make a lot of money. Sounds a lot like any other successful small business owner doesn't it? You are right. So what is the fuss all about?
The healthcare industry is gigantic, and growing by leaps and bounds. What we pay doctors on a per visit basis, is only a tiny fraction of that, and shrinking. So why do we even care? The reason all of those corporate types need to control doctors is because over 90% of healthcare spending that goes on in this country, some $2+ trillion, must be authorized by the signature of a physician!
Wow! That's it! It's not the doctors that matter to insurers and hospitals, it's that all of those trillions of dollars flow through a very narrow gate, and that very narrow gate is the pen of your doctor. Imagine the frustration of your Insurance or Hospital (or both) CEO. This gigantic medical industrial behemoth burning up trillions of dollars a year, lying there before him, and he can't touch it, or make it perform to his advantage, without the consent of the lowly doctor, that now is his employee, and makes a fraction of his cushy income. The frustration is epic. Is it any wonder he will stop at nothing to own your doctor, to make him do what needs to be done to make his bottom line fatter? Maybe even stoop to bribery?
This is where the doctor prostitute comes in. Now I don't say this lightly, and so far this is a small percentage of doctors, but it's starting to become more common. The doctor prostitute usually is a specialist that accounts for many expensive inpatient procedures, surgeries and tests. A good example is a cardio-thoracic surgeon, or cardiologist that does a lot of stents and angiograms. Now if you look at his personal productivity, compared with national benchmarks, you might see that this guy might make a salary at the very high end of specialists, like $400 to $500K, particularly if his productivity is well above the median. This is OK in my book. He is probably killing himself, and destroying his family and social life to do it, and if that is his choice, then so be it.
Now let's say there is a hospital that really wants a piece of the cardiac surgery, or cardiology business. Why you might say? Because that same doctor killing himself to make that high salary, is probably bringing $8-$10 million to the hospital that hosts his business. These estimates are probably low if anything, I assure you. So now you have that Hospital CEO desperate for this great line of business, in need of that doctor to make it happen. So how does he lure that doctor away from his current position? Well he just adds up the numbers, and figures out that if he slides $200 or $300K out of the hospital side, into that doctors pocket, he will more than make it up in the end.
Now the doctor is looking at doubling his salary for the same work. It would seem like an OK thing to do, no ethical dilemma here right? Wrong! It completely distorts the market. It creates a whole subset of doctors that don't get paid for what they do for their patients. They get paid partly from what they do for their patients, and partly from a direct kick-back in their salary from the corporation. And don't be fooled by the Hospitals and Insurers that call themselves "Not for Profit." Who are you kidding! As far as the public is concerned, the only difference between "For Profit" and "Not for Profit" corporations, is that the "For Profit" corporations actually pay taxes, and that helps us all. But that is a major topic for another day.
Now you might ask, why isn't it illegal for corporations to give Kick-Backs like this to doctors? Well it is, but there are lots of ways they can hide it. They don't just put it as a line item on that doctor's W-2 form at the end of the year "Kick-Back." No, they have to be very clever. One of the more clever ways for them to do it, is to cover all of that doctor's overhead, and hire him lots of expensive help to do all of the clean-up work after the surgeries. That frees up the surgeon to stay in the operating room, and on the assembly line, so to speak, which can make him super productive. Then when you look at his productivity, and it is now maybe at the 90th percentile, and not just the median, it looks like he just earned all of that extra money. In fact, it is just a scam. He didn't earn it at all, and it's really his patients that are getting short-changed.
Now why is it that his patients are getting short-changed you might say? Well when a doctor does a surgery, the Federal Guidelines actually spell out how much he gets paid for the various pieces of that surgery. A major surgery has what is called a "Global Period" for 90 days afterward. During that Global Period, the surgeon cannot charge for hospital rounds and follow-up visits in the office, and various other issues that come up after major surgery, as you can imagine. A big piece of the surgical package fee, is for the post-operative follow-up. Usually about 30% or more. The problem is, he isn't doing your follow-up. That's inefficient. His assistants of all sorts, are doing the work for him. Now who do you really want checking on you closely after bypass surgery, the assistant or the doctor? At most of these major heart centers, you may never see the surgeon, except as he sweeps by with his entourage in a minute flat. But you paid for his post-operative attention, not some assistant.
Doctors should get paid for what they do. They don't have to do it all, but what they do should at least reflect the guidelines. If 30% of the fee is for postop follow-up, then the effort should reflect that, on the part of the surgeon. If it is going to be done by others, that can be fine too, but the doctor should not get the entire 100%. He should get 70%, and the rest should go to the overhead of employing all of those assistants. I've seen arrangements where a hospital will provide so much support to the doctor that if he had covered that overhead for himself, he would have been bankrupt! Instead, with all that expensive help, he was able to ramp up his productivity so high, the salary was more than double what a typical doctor in the same specialty could command. All of this is just a big kick-back that is very hard to trace, and in the end, it is the Hospital or other big entity that winds-up raking in the dough, along with the over-paid doctor. As a physician and surgeon, I find the latter to be a particular affront, and I never miss an opportunity express my displeasure to any doctor whom I know has sold-out. I consider this completely unprofessional, their technical skills notwithstanding.
Now don't get me wrong. I used heart surgeons as an example, but there are plenty of other ways this goes on. Oncologists getting kick-backs on the administration of expensive chemotherapy drugs. Kidney specialists getting kick-backs on dialysis centers. Gastroenterologists getting kick-backs on endoscopy centers. The list goes on and on.
So how do we fix this? I will tell you how. The cost of ALL overhead, needs to come out of the revenue brought in by the doctor. The reimbursement is already set-up that way but is being perverted. It is the greed of some doctors to get paid excessively for what they do, and the clever accounting of the supporting hospitals that has distorted all of this, and it needs to stop! Doctors get paid well enough to do what they do, the way it was meant to be done. The damage comes when doctors allow themselves to be owned and controlled by corporations.
Most doctors get paid according to a set of rules known as C.P.T. coding. Almost everything that gets done in medicine has a code for the service provided. This "payment code," or "billing code" as it is more commonly known, is then generally linked to the patient by a Diagnosis Code, also known as an I.C.D. 9 code. That way, if a patient has the diagnosis of "appendicitis," it matches with the billing code submitted by the surgeon for "appendectomy."
There are vast books of diagnosis codes, and even larger more complex books filled with billing codes. How they apply in each and every conceivable patient care situation, creates almost limitless possibilities. Every type of provider you can think of, has their various codes for what they do. Every type of facility for providing services to patients has its billing codes as well. Are you starting to see what I mean when I say it is extremely complex? Doctors take classes frequently, just to keep up on the changes that occur most every year when a big group of government officials gets together and decides how much each service will be paid. Then it all gets posted in an official book called the "Federal Register."
Doctors don't bill in actual dollars when they perform a service. For billing purposes, everything we do has a "unit value." The units are referred to as "Physician Work Units." So for example, if you see your regular doctor for a typical 15 minute visit, he will submit a billing form with your diagnosis for that visit, and a billing code for what he did. This type of service is the most frequently rendered around the country, day in and day out, and is called an Evaluation and Management service. This particular example would render that doctor about "One Physician Work Unit." If he also performed a procedure, he would submit a code for that procedure in addition. An example would be a visit to the doctor to have your blood pressure checked, and a mole on your arm looked strange, so the doctor decides to do a skin biopsy at the same time.
Now how many work units are allowed for various procedures and visits, is extremely controversial and is a constantly undergoing revision as I had indicated. What is truly amazing is that the system works fairly well, for the most part. In general, the work units allowed for the various services rendered, are probably about as fair as it can be, given the politics of the Federal Government and the representatives of the various specialties. Many different variables are considered when assigning values to procedures. Some of these variables include the time it would be expected to take to do the procedure, the degree of extra specialty training required to do the procedure, the amount of post operative care that will be required of the doctor after the procedure which is generally included in the "surgical package," and the risk of malpractice that goes along with performing such a procedure. That is why a skin biopsy done in the office may render one work unit, and the removal of a brain tumor in the hospital, might be worth 40 work units.
Right about now, you are probably wondering, "what is a work unit worth in actual dollars?" That is a very good question. I will tell you that when a physician submits a bill, he actually gets paid according to a more comprehensive type of unit, called a R.V.U. or "relative value unit." This type of unit is actually a combination of the physician work units, the cost of facilities, and the cost of malpractice. If you look at any code in the Federal Register, it will give you the breakdown of each of the three components for that code, as a percentage of the total reimbursement allowed.
So again you ask, what does my doctor get paid for that 15 minute office visit? The answer is, "it depends". It depends on who is paying. Welfare/Medicaid pays about $28. Medicare pays about $37. Commercial insurers pay all over the map, but 150% to 200% of the Medicare rate is typical. These estimates are going to be very close, but not exact, because where you practice can affect reimbursement to some degree. Medicare doesn't vary much at all. That $37 give or take a buck, is going to be it, no matter where you practice. Welfare/Medicaid can vary widely depending on the state, and commercial insurance like most of us have, can pay all over the map, depending on how they can or cannot leverage doctors in that specific market. Lastly, let's not forget that most doctors get paid nothing for about 5% of the patients they see. So if you added up all of the R.V.U.'s, and all of the money collected, my guess is that it would probably be about $60 per R.V.U. on average,
Most doctors, by definition, are going to produce work units at around the median for their specialty. Surgeons and procedurally based specialists will produce more work units over the course of a year, than doctors who don't do a lot of procedures. Looking at the work unit data on thousands of doctors, all over the country in all of the various specialties, has found this to be true. So if you look at these doctors in their various specialties, and you take the median producers in each, you can get a data set that describes about how much that doctor will make, based on specialty. These data are widely available, but are generally proprietary in nature. One of the better data sets is called M.G.M.A., or Medical Group Management Association. There are others as well. And when you distill it all down, you can generally say that non-surgeon/non-procedure doctors are going to make about $150 to $200K, plus benefits, after expenses but before taxes, functioning at the median. The surgeons are going to do about $75 to $100K more. Surgeons train longer, by 2 years or more on average, and they work about 10 hours per week more on average, and they take more intense and more frequent after hours call, on average. That is why they produce proportionally more work units than non-surgeons. A very simple way to add it up, is to say that non-specialitst doctors make about $100 per hour, and specialist doctors make about $150 per hour. To both I would add about $20-$25 per hour in benefits.
So now you have a great insight into the financial world of doctors, complex as it may be. But you already know that they go to school and training for a ridiculously long time and take on all of that student loan debt, they work very hard long hours, and they make a lot of money. Sounds a lot like any other successful small business owner doesn't it? You are right. So what is the fuss all about?
The healthcare industry is gigantic, and growing by leaps and bounds. What we pay doctors on a per visit basis, is only a tiny fraction of that, and shrinking. So why do we even care? The reason all of those corporate types need to control doctors is because over 90% of healthcare spending that goes on in this country, some $2+ trillion, must be authorized by the signature of a physician!
Wow! That's it! It's not the doctors that matter to insurers and hospitals, it's that all of those trillions of dollars flow through a very narrow gate, and that very narrow gate is the pen of your doctor. Imagine the frustration of your Insurance or Hospital (or both) CEO. This gigantic medical industrial behemoth burning up trillions of dollars a year, lying there before him, and he can't touch it, or make it perform to his advantage, without the consent of the lowly doctor, that now is his employee, and makes a fraction of his cushy income. The frustration is epic. Is it any wonder he will stop at nothing to own your doctor, to make him do what needs to be done to make his bottom line fatter? Maybe even stoop to bribery?
This is where the doctor prostitute comes in. Now I don't say this lightly, and so far this is a small percentage of doctors, but it's starting to become more common. The doctor prostitute usually is a specialist that accounts for many expensive inpatient procedures, surgeries and tests. A good example is a cardio-thoracic surgeon, or cardiologist that does a lot of stents and angiograms. Now if you look at his personal productivity, compared with national benchmarks, you might see that this guy might make a salary at the very high end of specialists, like $400 to $500K, particularly if his productivity is well above the median. This is OK in my book. He is probably killing himself, and destroying his family and social life to do it, and if that is his choice, then so be it.
Now let's say there is a hospital that really wants a piece of the cardiac surgery, or cardiology business. Why you might say? Because that same doctor killing himself to make that high salary, is probably bringing $8-$10 million to the hospital that hosts his business. These estimates are probably low if anything, I assure you. So now you have that Hospital CEO desperate for this great line of business, in need of that doctor to make it happen. So how does he lure that doctor away from his current position? Well he just adds up the numbers, and figures out that if he slides $200 or $300K out of the hospital side, into that doctors pocket, he will more than make it up in the end.
Now the doctor is looking at doubling his salary for the same work. It would seem like an OK thing to do, no ethical dilemma here right? Wrong! It completely distorts the market. It creates a whole subset of doctors that don't get paid for what they do for their patients. They get paid partly from what they do for their patients, and partly from a direct kick-back in their salary from the corporation. And don't be fooled by the Hospitals and Insurers that call themselves "Not for Profit." Who are you kidding! As far as the public is concerned, the only difference between "For Profit" and "Not for Profit" corporations, is that the "For Profit" corporations actually pay taxes, and that helps us all. But that is a major topic for another day.
Now you might ask, why isn't it illegal for corporations to give Kick-Backs like this to doctors? Well it is, but there are lots of ways they can hide it. They don't just put it as a line item on that doctor's W-2 form at the end of the year "Kick-Back." No, they have to be very clever. One of the more clever ways for them to do it, is to cover all of that doctor's overhead, and hire him lots of expensive help to do all of the clean-up work after the surgeries. That frees up the surgeon to stay in the operating room, and on the assembly line, so to speak, which can make him super productive. Then when you look at his productivity, and it is now maybe at the 90th percentile, and not just the median, it looks like he just earned all of that extra money. In fact, it is just a scam. He didn't earn it at all, and it's really his patients that are getting short-changed.
Now why is it that his patients are getting short-changed you might say? Well when a doctor does a surgery, the Federal Guidelines actually spell out how much he gets paid for the various pieces of that surgery. A major surgery has what is called a "Global Period" for 90 days afterward. During that Global Period, the surgeon cannot charge for hospital rounds and follow-up visits in the office, and various other issues that come up after major surgery, as you can imagine. A big piece of the surgical package fee, is for the post-operative follow-up. Usually about 30% or more. The problem is, he isn't doing your follow-up. That's inefficient. His assistants of all sorts, are doing the work for him. Now who do you really want checking on you closely after bypass surgery, the assistant or the doctor? At most of these major heart centers, you may never see the surgeon, except as he sweeps by with his entourage in a minute flat. But you paid for his post-operative attention, not some assistant.
Doctors should get paid for what they do. They don't have to do it all, but what they do should at least reflect the guidelines. If 30% of the fee is for postop follow-up, then the effort should reflect that, on the part of the surgeon. If it is going to be done by others, that can be fine too, but the doctor should not get the entire 100%. He should get 70%, and the rest should go to the overhead of employing all of those assistants. I've seen arrangements where a hospital will provide so much support to the doctor that if he had covered that overhead for himself, he would have been bankrupt! Instead, with all that expensive help, he was able to ramp up his productivity so high, the salary was more than double what a typical doctor in the same specialty could command. All of this is just a big kick-back that is very hard to trace, and in the end, it is the Hospital or other big entity that winds-up raking in the dough, along with the over-paid doctor. As a physician and surgeon, I find the latter to be a particular affront, and I never miss an opportunity express my displeasure to any doctor whom I know has sold-out. I consider this completely unprofessional, their technical skills notwithstanding.
Now don't get me wrong. I used heart surgeons as an example, but there are plenty of other ways this goes on. Oncologists getting kick-backs on the administration of expensive chemotherapy drugs. Kidney specialists getting kick-backs on dialysis centers. Gastroenterologists getting kick-backs on endoscopy centers. The list goes on and on.
So how do we fix this? I will tell you how. The cost of ALL overhead, needs to come out of the revenue brought in by the doctor. The reimbursement is already set-up that way but is being perverted. It is the greed of some doctors to get paid excessively for what they do, and the clever accounting of the supporting hospitals that has distorted all of this, and it needs to stop! Doctors get paid well enough to do what they do, the way it was meant to be done. The damage comes when doctors allow themselves to be owned and controlled by corporations.
Sunday, February 24, 2008
Even an independent doctor can be "owned."
Even a completely independent doctor in his own practice, can be owned. You see, the corporate world knows how to make it look like a doctor has control of his practice, all the while they are pulling all of the strings. It really is a deception that is hard to identify, but you can figure it out if you know what signs to look for.
If the sign on the door identifies that practice as a subsidiary of a huge network, then the independence of each and every doctor in that subsidiary practice, will fall to the level of physician independence of the organization. Now believe me when I say that, in general, the bigger the system, the less independent the doctors will be, particularly if there is no other major competing system nearby. We have talked about exceptions like Kaiser, where all of the doctors work for themselves in a uniquely separate group, and there are other organizations as well that work this way, and I will get around to listing some of them, but I need to get a good look at their operation before I can comment.
Another way that doctors can appear independent and yet be owned, is in very small practices that get most of their referrals from one source. You will see this often when one system, and or one major hospital dominates an area, and control the primary care doctors. That is what big systems like to do, control the primary care doctors, and secretly direct their referrals to the specialists that support their hospital, and their labs, and scanners that rake in the dough. This is probably still OK as long as there is competition in the region. But watch out.
Most doctors really aren't very comfortable with this arrangement, but it can sneak up on them over time. The local hospital slowly buys up primary care practices, and employs those doctors, and after a while, the specialists become aware that the hospital owns 20%, 30% or maybe even 50% or more of their business. Then maybe they get a call from the hospital CEO who tells them how it's going to be, and if they don't like it, maybe the referrals can go to someone else, or maybe they will even go hire some doctor to compete head to head with them. Depending on the doctor's willingness to say no, they may be out of a job soon, and that is that. It starts out innocently enough, but it winds up like this all too often.
So you might say, how is it that a hospital, or integrated system with hospitals, doctors, and insurance, is able to just go out and find a doctor to compete with an independent local physician. Doctors don't just grow on trees, and there is a shortage that is worsening quickly. What is in it for him. The answer is money, of course.
This brings up one of the most disturbing issues in medicine today, at least that is how I see it as a doctor, and you should see it as a patient. Doctors are selling themselves to the highest bidder. Now I doubt you are surprised by that statement, but you should be shocked because of the ramifications of that fact. And all of this leads us to another rule.
Fifth Rule:
Any doctor that gets paid substantially more money, by an employer, than is justified by his personal productivity and time on duty, less overhead costs (with few exceptions) is basically just the medical equivalent of a prostitute.
This is a very strong statement I know, but it is fundamental to what is wrong in healthcare today. A small group of doctors is making it worse for all of us, doctors and patients alike. In the end, it will sell us all out, along with the doctor patient relationship.
If the sign on the door identifies that practice as a subsidiary of a huge network, then the independence of each and every doctor in that subsidiary practice, will fall to the level of physician independence of the organization. Now believe me when I say that, in general, the bigger the system, the less independent the doctors will be, particularly if there is no other major competing system nearby. We have talked about exceptions like Kaiser, where all of the doctors work for themselves in a uniquely separate group, and there are other organizations as well that work this way, and I will get around to listing some of them, but I need to get a good look at their operation before I can comment.
Another way that doctors can appear independent and yet be owned, is in very small practices that get most of their referrals from one source. You will see this often when one system, and or one major hospital dominates an area, and control the primary care doctors. That is what big systems like to do, control the primary care doctors, and secretly direct their referrals to the specialists that support their hospital, and their labs, and scanners that rake in the dough. This is probably still OK as long as there is competition in the region. But watch out.
Most doctors really aren't very comfortable with this arrangement, but it can sneak up on them over time. The local hospital slowly buys up primary care practices, and employs those doctors, and after a while, the specialists become aware that the hospital owns 20%, 30% or maybe even 50% or more of their business. Then maybe they get a call from the hospital CEO who tells them how it's going to be, and if they don't like it, maybe the referrals can go to someone else, or maybe they will even go hire some doctor to compete head to head with them. Depending on the doctor's willingness to say no, they may be out of a job soon, and that is that. It starts out innocently enough, but it winds up like this all too often.
So you might say, how is it that a hospital, or integrated system with hospitals, doctors, and insurance, is able to just go out and find a doctor to compete with an independent local physician. Doctors don't just grow on trees, and there is a shortage that is worsening quickly. What is in it for him. The answer is money, of course.
This brings up one of the most disturbing issues in medicine today, at least that is how I see it as a doctor, and you should see it as a patient. Doctors are selling themselves to the highest bidder. Now I doubt you are surprised by that statement, but you should be shocked because of the ramifications of that fact. And all of this leads us to another rule.
Fifth Rule:
Any doctor that gets paid substantially more money, by an employer, than is justified by his personal productivity and time on duty, less overhead costs (with few exceptions) is basically just the medical equivalent of a prostitute.
This is a very strong statement I know, but it is fundamental to what is wrong in healthcare today. A small group of doctors is making it worse for all of us, doctors and patients alike. In the end, it will sell us all out, along with the doctor patient relationship.
Friday, February 1, 2008
Ever heard of the Corporate Practice of Medicine?
Have you ever heard of the "Corporate Practice of Medicine." States like California have laws against non-physicians, making decisions about patient care. That is a good idea because the MBA or lawyer that runs your insurance company or Hospital didn't go to Medical School, but that won't keep him from telling his employee doctors how to treat their patients. However, those physician-owning administrators will try to get their say one way or another, you can bet on that.
I like to think that doctors will always put the best interests of the patient first. Maybe it is because I am a doctor too. Just in case you were wondering, I am a board certified surgeon, practicing full time, and taking emergency room call one third of my life. I live in the trenches, so I don't just talk the talk, I walk the walk too. But even I will tell you that no compensation system for doctors ever conceived, is without conflict of interest. Even if the patient pays you in cash or livestock for your medical services, a doctor could be accused of recommending more than necessary just to run up the bill. But I do believe that such a simple system of compensating doctors is certainly going to have the least conflict of all.
Since medical care is high tech, and very expensive, it is likely that patients will continue to pay their doctor through an insurer of some sort. This other entity that pays for the patient is commonly referred to as the "third party". Trading livestock for surgery isn't going to make a comeback, in my opinion. All of this is critical to understanding the various factors that can put pressure on your doctor, and maybe sway his treatment opinion. As the patient, you should try to understand how it is that your doctor gets paid. It is fundamental to your relationship with him.
A doctor has to get paid one way or another, or he is out of business, and you don't get care. This isn't a bad thing, that doctors get paid, despite what you may have been told. You want your doctor to get paid, and paid well. It will keep him available, and willing to slog into the ER in the middle of the night to take out your appendix. It allows him to have a nice house, and be part of the community, and build relationships. All of this makes him more accountable to the community, and gives him a reputation to nurture and protect.
If a promising doctor to be, sees that he won't make much money, how likely is he to go through eight or more years of school, and do a residency for 3 - 9 years, and rack up six figure debt, and put off much of his life until his early thirties? This is what it takes to be a doctor. It is a long hard expensive road, and few would begin down that road without the promise of a comfortable living.
You want your doctor to be paid a comfortable living because that is what it will take to have him available when you need him, and have him care about doing a good job. It's just the same as the owner of a business. It's all about reputation. And by the way, the average doctor makes similar wages as any other small business owner that has as many employees, particularly if you calculate wages per hour worked. Keep that in mind. How many years did the owner of that favorite restaurant put in to make the kind of money he makes?
If we then try put all of the money concerns aside, what kinds of outside influences might significantly affect the types of decisions that get made by your doctor, concerning your care, every day? I would assert again that probably the biggest influence is held by whomever can fire him from his practice. This begs the question, who should have such control? The answer to this question is absolutely key to your relationship with your doctor, yet few patients even know. Next time you see your doctor, just ask him, who is your boss? Who can walk in here right now and make you pack up your things and leave? The answer you want to hear is "nobody."
First Rule:
Your doctor ideally, will not practice in a setting where he can be fired, except for breaking the law, or having his license suspended.
The two are not the same. The higher standard is with the state medical board. Having sexual relations with a patient whom is a consenting adult, is not against the law, but it will get your license suspended. Most any felony conviction, and many misdemeanors will get a doctor's license suspended or revoked fully, as well.
Now when a new doctor is brought into a practice, there is generally an associate term during which he can be "let go" if it doesn't work out. This is appropriate, but probably not for more than two or three years at most. A doctor with an established reputation, in the community needs to know what kind of person this new doctor really is, and it can take awhile. Still, during this time, that associate doctor is under scrutiny, but really this cannot be avoided.
Some doctors are brought in strictly as employees, and can be fired at will for whatever reason. Many an employee doctor has been let go for doing his job too well, and taking business away from a partner. This arrangement is not ideal for the patients, and if you are a patient in an established practice, and find out that such arrangements exist long term, you may want to write a letter to the partners of that practice, and voice your disapproval.
So what happens if you cannot get a straight answer about whom your doctor works for? You should then assume that your doctor has a boss that can fire him, no questions asked. Any doctor that is his own boss will tell you straight out, loud and proud. These days, more and more doctors are under pressure to sell-out and become an employee. It's an easy path to follow, selling-out is, and with rare exception, no doctor does it for the benefit of his patients. Any doctor that is his own boss knows the sacrifice it takes, and really does want patients to know it, but they hardly ever ask. You should ask, but prepare to be surprised.
Second Rule:
If a doctor is his own boss, and cannot be fired except for breaking the law and losing his license, he will be happy to tell you so.
Now what if a doctor works for some big giant integrated system like Kaiser? Should we assume that he is merely and employee. No, not necessarily. Kaiser doctors all become equal shareholders in the Permanente Medical Group. They really can't be fired without due process from their peers. In this respect, the largest, and most respected HMO in the business, really does look out for its physician patient relationship. Very few big systems or groups can make that statement. That might be why Kaiser does very well recruiting physicians without having to overpay.
Third Rule:
If doctors are in charge of a health care organization, you will see them dominating the Board of Directors of that organization, and the administrators of that organization, even the CEO, will tell you that they work for the doctors, and not the other way around.
This can be a little bit tricky, particularly with Hospital Systems. Each hospital will have a Board that will include members of the medical and nursing staff. This is a working hospital board, and those people are critical to day to day decision making. To dig deeper, you need to look at the make-up of the corporate board, that makes decisions for the entire system. The corporate board will look very different, as it is not involved in day to day clinical operations. This board sets the long term agenda, and hands down orders to the lesser boards to carry out. This is the ultimate authority about all issues, and it is usually going to be stacked with money people, lawyers, clergy, and maybe politicians. Maybe they will have some doctor in an advisory role, for show, just to say a doctor is involved, but you can be sure that doctors are not the boss in this type of organization. I know of one large system whose CEO got a doctorate in finance and made sure everything written about him referred to him as doctor. This just confuses the public, because they think that CEO is a medical doctor. A local physician-owned group specifically told him to stop misleading the public on the matter. Kudos to them, but it was a gutsy move, as that CEO employs most of the doctors in that region.
Unfortunately, these large integrated systems with multiple hospitals, and hundreds of employee physicians, are rapidly becoming the norm. Most of them are now launching their own insurance companies, since that is where the real money is. It is conceivable that if they capture enough of the local market, they can then spin-out most the doctors back to private practice, and control them with insurance contracts, which then then unavoidable for the local doctors. Still, in my opinion, that would be better off for patients.
Fourth Rule:
Even a completely independent doctor, who is his own boss, can be utterly controlled by a big system, if he does too much insurance business with them, or gets too many referrals from them, or depends on their facilities solely, or mostly, for his practice. That is also why it is essential to have an independent physician voice at the level of the highest board of directors of all Hospital/Insurance organizations. Particularly if that organization dominates a geographic region, such that patients must travel a significant distance to seek medical care from a different provider. Indeed, competition is good, for a variety of reasons.
I like to think that doctors will always put the best interests of the patient first. Maybe it is because I am a doctor too. Just in case you were wondering, I am a board certified surgeon, practicing full time, and taking emergency room call one third of my life. I live in the trenches, so I don't just talk the talk, I walk the walk too. But even I will tell you that no compensation system for doctors ever conceived, is without conflict of interest. Even if the patient pays you in cash or livestock for your medical services, a doctor could be accused of recommending more than necessary just to run up the bill. But I do believe that such a simple system of compensating doctors is certainly going to have the least conflict of all.
Since medical care is high tech, and very expensive, it is likely that patients will continue to pay their doctor through an insurer of some sort. This other entity that pays for the patient is commonly referred to as the "third party". Trading livestock for surgery isn't going to make a comeback, in my opinion. All of this is critical to understanding the various factors that can put pressure on your doctor, and maybe sway his treatment opinion. As the patient, you should try to understand how it is that your doctor gets paid. It is fundamental to your relationship with him.
A doctor has to get paid one way or another, or he is out of business, and you don't get care. This isn't a bad thing, that doctors get paid, despite what you may have been told. You want your doctor to get paid, and paid well. It will keep him available, and willing to slog into the ER in the middle of the night to take out your appendix. It allows him to have a nice house, and be part of the community, and build relationships. All of this makes him more accountable to the community, and gives him a reputation to nurture and protect.
If a promising doctor to be, sees that he won't make much money, how likely is he to go through eight or more years of school, and do a residency for 3 - 9 years, and rack up six figure debt, and put off much of his life until his early thirties? This is what it takes to be a doctor. It is a long hard expensive road, and few would begin down that road without the promise of a comfortable living.
You want your doctor to be paid a comfortable living because that is what it will take to have him available when you need him, and have him care about doing a good job. It's just the same as the owner of a business. It's all about reputation. And by the way, the average doctor makes similar wages as any other small business owner that has as many employees, particularly if you calculate wages per hour worked. Keep that in mind. How many years did the owner of that favorite restaurant put in to make the kind of money he makes?
If we then try put all of the money concerns aside, what kinds of outside influences might significantly affect the types of decisions that get made by your doctor, concerning your care, every day? I would assert again that probably the biggest influence is held by whomever can fire him from his practice. This begs the question, who should have such control? The answer to this question is absolutely key to your relationship with your doctor, yet few patients even know. Next time you see your doctor, just ask him, who is your boss? Who can walk in here right now and make you pack up your things and leave? The answer you want to hear is "nobody."
First Rule:
Your doctor ideally, will not practice in a setting where he can be fired, except for breaking the law, or having his license suspended.
The two are not the same. The higher standard is with the state medical board. Having sexual relations with a patient whom is a consenting adult, is not against the law, but it will get your license suspended. Most any felony conviction, and many misdemeanors will get a doctor's license suspended or revoked fully, as well.
Now when a new doctor is brought into a practice, there is generally an associate term during which he can be "let go" if it doesn't work out. This is appropriate, but probably not for more than two or three years at most. A doctor with an established reputation, in the community needs to know what kind of person this new doctor really is, and it can take awhile. Still, during this time, that associate doctor is under scrutiny, but really this cannot be avoided.
Some doctors are brought in strictly as employees, and can be fired at will for whatever reason. Many an employee doctor has been let go for doing his job too well, and taking business away from a partner. This arrangement is not ideal for the patients, and if you are a patient in an established practice, and find out that such arrangements exist long term, you may want to write a letter to the partners of that practice, and voice your disapproval.
So what happens if you cannot get a straight answer about whom your doctor works for? You should then assume that your doctor has a boss that can fire him, no questions asked. Any doctor that is his own boss will tell you straight out, loud and proud. These days, more and more doctors are under pressure to sell-out and become an employee. It's an easy path to follow, selling-out is, and with rare exception, no doctor does it for the benefit of his patients. Any doctor that is his own boss knows the sacrifice it takes, and really does want patients to know it, but they hardly ever ask. You should ask, but prepare to be surprised.
Second Rule:
If a doctor is his own boss, and cannot be fired except for breaking the law and losing his license, he will be happy to tell you so.
Now what if a doctor works for some big giant integrated system like Kaiser? Should we assume that he is merely and employee. No, not necessarily. Kaiser doctors all become equal shareholders in the Permanente Medical Group. They really can't be fired without due process from their peers. In this respect, the largest, and most respected HMO in the business, really does look out for its physician patient relationship. Very few big systems or groups can make that statement. That might be why Kaiser does very well recruiting physicians without having to overpay.
Third Rule:
If doctors are in charge of a health care organization, you will see them dominating the Board of Directors of that organization, and the administrators of that organization, even the CEO, will tell you that they work for the doctors, and not the other way around.
This can be a little bit tricky, particularly with Hospital Systems. Each hospital will have a Board that will include members of the medical and nursing staff. This is a working hospital board, and those people are critical to day to day decision making. To dig deeper, you need to look at the make-up of the corporate board, that makes decisions for the entire system. The corporate board will look very different, as it is not involved in day to day clinical operations. This board sets the long term agenda, and hands down orders to the lesser boards to carry out. This is the ultimate authority about all issues, and it is usually going to be stacked with money people, lawyers, clergy, and maybe politicians. Maybe they will have some doctor in an advisory role, for show, just to say a doctor is involved, but you can be sure that doctors are not the boss in this type of organization. I know of one large system whose CEO got a doctorate in finance and made sure everything written about him referred to him as doctor. This just confuses the public, because they think that CEO is a medical doctor. A local physician-owned group specifically told him to stop misleading the public on the matter. Kudos to them, but it was a gutsy move, as that CEO employs most of the doctors in that region.
Unfortunately, these large integrated systems with multiple hospitals, and hundreds of employee physicians, are rapidly becoming the norm. Most of them are now launching their own insurance companies, since that is where the real money is. It is conceivable that if they capture enough of the local market, they can then spin-out most the doctors back to private practice, and control them with insurance contracts, which then then unavoidable for the local doctors. Still, in my opinion, that would be better off for patients.
Fourth Rule:
Even a completely independent doctor, who is his own boss, can be utterly controlled by a big system, if he does too much insurance business with them, or gets too many referrals from them, or depends on their facilities solely, or mostly, for his practice. That is also why it is essential to have an independent physician voice at the level of the highest board of directors of all Hospital/Insurance organizations. Particularly if that organization dominates a geographic region, such that patients must travel a significant distance to seek medical care from a different provider. Indeed, competition is good, for a variety of reasons.
Thursday, January 31, 2008
Who Owns Your Doctor?
This Blog Site is dedicated to the truth about what is happening in health care in America today. Look around on the Internet, and you can find all kinds of information about Hospitals and Doctors. Insurance companies have even hired companies like Zagat, to tell you who the best doctors are, and who runs the best practices, and why. Has it come to this? Would you pick your doctor like you would pick your hotel or restaurant?
What really matters in choosing a doctor anyway? I have asked this of my patients over the years, and I have come up with some very consistent answers. Patients want a doctor who is kind, caring, honest and competent. They also want a doctor who is available when they need him, or can at least get them seen by a colleague in time of need. Lastly, they want to know that their doctor is working for them, and looking after their needs as a patient first.
Let's think about what it means for a doctor to be working for his patients. I would like to define that more specifically. What does that really mean? Did you ever ask yourself, "who does my doctor work for?" How do you even define what it means to work for someone, or some organization?
It has been said that, "your boss is the one that can fire you." As a patient, you can certainly fire your doctor, no questions asked. Now if you have an established relationship, your doctor cannot fire you, without making certain accommodations to transfer your care to another doctor. In that respect the patient is the boss in this relationship.
Now if you fire your doctor, as one patient, it probably isn't going to have a great impact on his career. He won't have to sell the house and move his family to a new city and start a new job and all of that. The true boss for that doctor is the guy that can tell him he has to move his practice elsewhere, at great expense of time, money, and energy. Not to mention aggravation on the part of himself, and his family.
So when you think this all through, your doctor's real boss isn't you, the patient, it is whomever can fire him. So if it comes down to decisions about the running of a practice, and expenses and overhead, and profits, and making that practice viable as an ongoing economic concern, who do you think is going to have the greatest influence over the decision making, the patient, or the the guy that can fire your doctor?
Now in light of this new line of thinking, does it matter to you that your doctor might be worried about losing his job if he decides to recommend the more expensive treatment, or he wants to keep you in the hospital an extra night? It should, because that is exactly what is going on out there my friends. Doctors are selling out left and right, to insurance companies, to hospitals, and to administrative types (some of whom used to be doctors) that are now calling the shots on your care, because the doctor that is treating you is wondering if he will get fired, for doing what is best for you.
How do you know if your doctor is a sell-out? I am going to tell you how in future discussions.
What really matters in choosing a doctor anyway? I have asked this of my patients over the years, and I have come up with some very consistent answers. Patients want a doctor who is kind, caring, honest and competent. They also want a doctor who is available when they need him, or can at least get them seen by a colleague in time of need. Lastly, they want to know that their doctor is working for them, and looking after their needs as a patient first.
Let's think about what it means for a doctor to be working for his patients. I would like to define that more specifically. What does that really mean? Did you ever ask yourself, "who does my doctor work for?" How do you even define what it means to work for someone, or some organization?
It has been said that, "your boss is the one that can fire you." As a patient, you can certainly fire your doctor, no questions asked. Now if you have an established relationship, your doctor cannot fire you, without making certain accommodations to transfer your care to another doctor. In that respect the patient is the boss in this relationship.
Now if you fire your doctor, as one patient, it probably isn't going to have a great impact on his career. He won't have to sell the house and move his family to a new city and start a new job and all of that. The true boss for that doctor is the guy that can tell him he has to move his practice elsewhere, at great expense of time, money, and energy. Not to mention aggravation on the part of himself, and his family.
So when you think this all through, your doctor's real boss isn't you, the patient, it is whomever can fire him. So if it comes down to decisions about the running of a practice, and expenses and overhead, and profits, and making that practice viable as an ongoing economic concern, who do you think is going to have the greatest influence over the decision making, the patient, or the the guy that can fire your doctor?
Now in light of this new line of thinking, does it matter to you that your doctor might be worried about losing his job if he decides to recommend the more expensive treatment, or he wants to keep you in the hospital an extra night? It should, because that is exactly what is going on out there my friends. Doctors are selling out left and right, to insurance companies, to hospitals, and to administrative types (some of whom used to be doctors) that are now calling the shots on your care, because the doctor that is treating you is wondering if he will get fired, for doing what is best for you.
How do you know if your doctor is a sell-out? I am going to tell you how in future discussions.
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