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.
Sunday, February 24, 2008
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.
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