Malpractice and Defensive Medicine
Here is where I complain about doctors being unreasonable, and not doing a better job for patients.
Unfortunately, doctors make mistakes. Modern health care is complex, the treatments are more and more dangerous, and we are practicing on older and sicker patients who all expect to cheat death until they are 100.
If you look at a the chart of a 90 year old patient, who spent the last 2 months of her life in the ICU (all too common these days), I can just about guarantee you will find that preventable mistakes were made. It would be nice if no mistakes ever were made. The reality is that 100,000 or more patients die each year in America, sooner than they should have, because of these mistakes. We need to do better.
The threat of lawsuits haunts us doctors, and is a constant incentive to try and do better. Lawyers deserve credit for keeping us on our toes.
The cost of legal defense for malpractice is really only about $2 billion yearly. This is a drop in the health care cost bucket. Doctors shout for Tort reform, but Tort reform has never been shown to lower health care costs in states where it is in effect. It also makes adversaries of doctors and lawyers who both work for their respective patients and clients.
The real cost to the system, is the cost of defensive medicine. These are the unnecessary tests and procedures physicians do, mostly, if not wholly, to be able to say we were very thorough, should a bad outcome occur. This is the result of juries, who take a very dim view of any doctor who didn't do everything possible to diagnose and treat an ailment, that went on to cause a bad outcome. The same jury will acquit a doctor who over-treats a patient, leading to a serious complication. This is the well known psychology of the jury, and even in this age of information, it greatly affects the practice of medicine.
The cost of treating and testing unnecessarily is huge. Some would put it in the range of $200+ billion yearly. Since tests are part of the Stuff that is the root cause of health care inflation, it needs to be tamed. So how do we do this?
The reality is that most doctors follow certain standard of care protocols, but will do more than those protocols suggest frequently, because they will suffer the consequences if the protocol fails. And it will fail very infrequently, but you don't want to be the doctor treating the patient when it does fail.
The solution is to make a deal with the lawyers. Let's follow the very best data we have, for treatment of the presenting problem. If the protocol says an expensive test isn't necessary, then it won't be done. But if the outcome is bad, even though the protocol was followed, the doctor will be held harmless.
Now the lawyers will not like this. But we can give them an even better offer, because the savings from not doing all of those tests, will result in a giant pool of money, far greater than the $2 billion malpractice business which now exists. In fact, you could create a hypothetical " bad outcomes pool" of $10-20 billion, which is 10x the typical amount of yearly malpractice costs, and still save 10x more than that because of all those tests that weren't done. That's real money!
So take the $200 billion in savings on testing, and give $10-20 billion to the lawyers, and put them in charge of compensating patients and their families for bad outcomes. After all, compensation for loss is tricky business, best left to the lawyers. It takes skill and expertise that certainly most doctors do not possess, and lawyers deserve fair compensation for such service.
The real win is for the consumer, because turning back all of that unnecessary testing should lower costs. Also, it is a statistical fact that doctors will be delivering better care, with fewer bad outcomes. And that will bear out over time. Then we can focus on improving the process to continue to reduce the bad outcomes. Everybody wins right? Well sort of.
So who will lose under this scheme? Of course it is the makers of the Stuff. And they will do their very best to make sure such a sensible alliance between doctors and lawyers for the public good, never happens. You can bank on that.
Tuesday, February 12, 2013
The Stuff
By now you must be wondering what is the cause of this massive healthcare inflation we have seen over the last 30 + years. After all it was so easy and convenient to point fingers at the doctors. But doctors care about patients, and what they want most, is simply to get their patients what they need. That's what doctors do.
To fully understand this health care cost crisis, it important that you know about the "Stuff". The Stuff, is my shorthand for all of the collective new and expensive drugs and medical technologies. This includes drugs, tests, implants, surgeries and surgical equipment, testing equipment, and medical treatment equipment necessary for various therapies. For the most part, these are tangible things that are made and sold by various companies domestic and foreign. They almost universally require FDA approval in the US.
The best studies done to date, regarding heath care cost inflation, show that it is the cost of the Stuff, that drives this inflation. (kff.org/insurance/7670.cfm ) Think about it. Thirty years ago we didn't have all of the Stuff, that we have now. That's why health care costs made up half as much of the economy then, as it does now. So what we all really need to be asking ourselves is: "Why does the Stuff have to cost so much"?
That is a very good question indeed, particularly when that same Stuff, and sometimes even better Stuff, can be gotten in other countries for significantly less. Hey, we all know it is true. Millions of Americans get drugs and treatments outside of the US every year, at a fraction of the cost. And technically speaking, it is generally illegal to do so. So why can't we just get that Stuff right here, for less, and not have to break the law? It really is that simple, despite what you hear. Well almost anyway.
It turns out that the Stuff is more than just things. It also refers to the manipulation of all of these things by politicians, and other interested parties, even including companies from other countries. Yes it goes that far. It's the reason that the Stuff costs so much more in America than everywhere else in the world.
Companies around the world are inventing new medical treatments of all sorts too. These new treatments then get American patents, and FDA approval, even though they may be only marginal improvements, or not even as effective as what is already available off-patent. This is particularly true for drugs. Because congress forbids Medicare and Medicaid from negotiating lower prices on FDA approved treatments, they can advertise and sell in the US market at far higher prices than they can in all other markets or their own market. Americans pay much higher prices than anywhere else in the world. In effect, Americans are subsidizing new treatments for people all over the world, and we are also the cash cow for foreign companies who make the Stuff too. Is it any wonder we're going broke over health care?
Now politicians and makers of the Stuff, really don't want you to know about this, so they try hard to convince the public that the problem is all of those greedy doctors. And they would be right about a very, very, tiny number of doctors who actually do make millions of dollars helping companies sell their expensive Stuff. But the vast majority of doctors do not engage in helping these companies sell their Stuff. In reality, your doctor really wants the stuff to cost much less too. If for no other reason, it's so they don't have to constantly hear their patients complain about the high cost of the Stuff!
You know in all of my years in medicine, no salesman selling Stuff for his company, ever ever asked me how much I thought that Stuff should cost. Further, I have asked hundreds of doctors personally, whether they were ever asked to weigh in on the cost of any of the Stuff, that these salesmen wanted us to recommend for our patients. Not a one said they ever had any input about the cost, nor were they ever even asked.
So there you have my very unscientific take on physician participation, in deciding about the cost of the Stuff. But just ask your doctor if he has ever heard a complaint about the high cost of the Stuff? Undoubtedly he will tell you that he hears about it every day......
By now you must be wondering what is the cause of this massive healthcare inflation we have seen over the last 30 + years. After all it was so easy and convenient to point fingers at the doctors. But doctors care about patients, and what they want most, is simply to get their patients what they need. That's what doctors do.
To fully understand this health care cost crisis, it important that you know about the "Stuff". The Stuff, is my shorthand for all of the collective new and expensive drugs and medical technologies. This includes drugs, tests, implants, surgeries and surgical equipment, testing equipment, and medical treatment equipment necessary for various therapies. For the most part, these are tangible things that are made and sold by various companies domestic and foreign. They almost universally require FDA approval in the US.
The best studies done to date, regarding heath care cost inflation, show that it is the cost of the Stuff, that drives this inflation. (kff.org/insurance/7670.cfm ) Think about it. Thirty years ago we didn't have all of the Stuff, that we have now. That's why health care costs made up half as much of the economy then, as it does now. So what we all really need to be asking ourselves is: "Why does the Stuff have to cost so much"?
That is a very good question indeed, particularly when that same Stuff, and sometimes even better Stuff, can be gotten in other countries for significantly less. Hey, we all know it is true. Millions of Americans get drugs and treatments outside of the US every year, at a fraction of the cost. And technically speaking, it is generally illegal to do so. So why can't we just get that Stuff right here, for less, and not have to break the law? It really is that simple, despite what you hear. Well almost anyway.
It turns out that the Stuff is more than just things. It also refers to the manipulation of all of these things by politicians, and other interested parties, even including companies from other countries. Yes it goes that far. It's the reason that the Stuff costs so much more in America than everywhere else in the world.
Companies around the world are inventing new medical treatments of all sorts too. These new treatments then get American patents, and FDA approval, even though they may be only marginal improvements, or not even as effective as what is already available off-patent. This is particularly true for drugs. Because congress forbids Medicare and Medicaid from negotiating lower prices on FDA approved treatments, they can advertise and sell in the US market at far higher prices than they can in all other markets or their own market. Americans pay much higher prices than anywhere else in the world. In effect, Americans are subsidizing new treatments for people all over the world, and we are also the cash cow for foreign companies who make the Stuff too. Is it any wonder we're going broke over health care?
Now politicians and makers of the Stuff, really don't want you to know about this, so they try hard to convince the public that the problem is all of those greedy doctors. And they would be right about a very, very, tiny number of doctors who actually do make millions of dollars helping companies sell their expensive Stuff. But the vast majority of doctors do not engage in helping these companies sell their Stuff. In reality, your doctor really wants the stuff to cost much less too. If for no other reason, it's so they don't have to constantly hear their patients complain about the high cost of the Stuff!
You know in all of my years in medicine, no salesman selling Stuff for his company, ever ever asked me how much I thought that Stuff should cost. Further, I have asked hundreds of doctors personally, whether they were ever asked to weigh in on the cost of any of the Stuff, that these salesmen wanted us to recommend for our patients. Not a one said they ever had any input about the cost, nor were they ever even asked.
So there you have my very unscientific take on physician participation, in deciding about the cost of the Stuff. But just ask your doctor if he has ever heard a complaint about the high cost of the Stuff? Undoubtedly he will tell you that he hears about it every day......
Sunday, February 10, 2013
The Health Care Cost Crisis
American health care is at a crossroads of sorts. We all know it. But do we know how we got here and who is responsible? Probably not. I have talked to some of the brightest minds in the health care industry over my 25+ years as a physician and surgeon, and I remain bemused and befuddled by the things I hear, and the so-called experts whom I hear it from.
First off, we do not have a health care crisis. We have a health care "cost" crisis. There is a big difference. If we were, as a nation, spending 9% of GDP on health care like we did in 1980, then it wouldn't be destroying the national budget. Instead we are now spending and astounding 18% of GDP! It cannot go on. If we could get it back to 10% or less of GDP, the economists, who know about this kind of stuff, say that level is ""sustainable" over time. The savings from bringing health care costs back to 1980 levels, would balance the budget. Imagine no budget deficit. Wow! What would politicians have to argue about? Suffice it to say that health care costs are wrecking our economy. And Congress has more or less finally agreed to this fact. When one sector of the economy doubles its percentage of that economy, in a generation, something has got to give.
Now if we assume that health care is our primary economic issue, then who is to blame? This is where things get tricky. The preponderance of opinion on the matter, is that most of the blame falls squarely on the doctors. Why is that you may ask? Well as I said before, roughly 90% of that spending requires the authorization of your doctor in one way or another, so it's easy to lay blame there. But of course, that is pure propaganda and misdirection from the real truth of the matter. The fact is that the medical industrial complex wants you to believe that doctors are the problem. They also want you to believe that doctors are wealthy and arrogant, and that the only way to control health care costs is to own them, and control them to their own advantage. The thing is, the public is buying into that propaganda. So lets explore this assertion.
First, lets really look at how much doctors get out of that 18% of GDP pie. You may be surprised to find that the physician piece of it is shrinking steadily. One trick of accounting is that they love to lump all of the doctors in with the rest of the "providers". But doctors take the blame, so let's look closely at the numbers, but just for doctors. There are about 800,000 MD's and DO's (full time equivalents) practicing in America today. These are the "real doctors" you hear about. You know, the Mercedes driving, golf clubs in the trunk, Country Club going types you always hear about. This gang makes (on average) $200,000 in gross wages, and $50,000 in benefits yearly. If you multiply $250,000 by 800,000, you see that all of the real doctors garner about $200 billion. Not bad, but when you divide that by the $2.7 trillion in total health care spending annually, you find that it amounts to a whopping 7.4 pennies on the dollar. That's right, less than 7.5 cents of your health care dollar goes to the real doctors. And, it is less and less every year. Physician wages are a deflationary part of the overall health care cost crisis, so in that sense, we are already doing our part to solve the problem.
The next thing you hear about, is that doctors practice in a way that over-treats patients. The data for this is based on regional variations in the numbers and types of expensive tests and procedures. But that data is extremely biased and flawed because it is based on availability, not on the validity of the treatment. If you have an arthritic hip, and a good hip replacement surgeon is available locally, you are more likely to have it done, rather than continue to take pain medicine. It's a quality of life decision. It doesn't mean the treatment is inappropriate. Besides, it's the patient that makes the decision. The doctor just offers the treatment. So who is to blame?
I've heard it said again and again, that doctors should not be paid fee-for-service. Fine, but will that make any difference in costs over time? No. Back in 1980 the vast majority of doctors were paid fee-for-service and, as noted, health care costs were half of what they are now, as a percentage of GDP. Also, if you look at a mature managed care system like Kaiser Permanente, where the physicians are paid a salary, and there is no incentive whatsoever for them to treat, or test patients excessively, you will find that their insurance premium costs are no lower than the competition. Further, they do it with the lowest administrative fees of any health care organization in the country, spending only 5% of the premium dollar on paperwork, and 95% on actual health care for their members. If putting all of your doctors on salary led to lower utilization and lower costs, the entire health care system would be one big Kaiser Permanente by now, because nobody would be able to compete. Obviously this has not happened, and that is because what you are hearing about doctors being the culprits, simply isn't true.
Doctors are the scapegoats in all of this, and we also are the target of a smear campaign by the true perpetrators of this economic disaster that is the US health care system. Doctors put patients ahead of politics, and try to rise above vitriol. It is more from the lack of guidance by physicians, that we are in the situation we are in. If you want to fault the physicians, fault them for being silent for too long, and for allowing themselves to be gagged by signing employment contracts that won't let them speak out about the real cause of runaway health care cost inflation.
No, physicians are not blameless, but their shrinking piece of the action speaks volumes about whom is really profiting from all of this.
American health care is at a crossroads of sorts. We all know it. But do we know how we got here and who is responsible? Probably not. I have talked to some of the brightest minds in the health care industry over my 25+ years as a physician and surgeon, and I remain bemused and befuddled by the things I hear, and the so-called experts whom I hear it from.
First off, we do not have a health care crisis. We have a health care "cost" crisis. There is a big difference. If we were, as a nation, spending 9% of GDP on health care like we did in 1980, then it wouldn't be destroying the national budget. Instead we are now spending and astounding 18% of GDP! It cannot go on. If we could get it back to 10% or less of GDP, the economists, who know about this kind of stuff, say that level is ""sustainable" over time. The savings from bringing health care costs back to 1980 levels, would balance the budget. Imagine no budget deficit. Wow! What would politicians have to argue about? Suffice it to say that health care costs are wrecking our economy. And Congress has more or less finally agreed to this fact. When one sector of the economy doubles its percentage of that economy, in a generation, something has got to give.
Now if we assume that health care is our primary economic issue, then who is to blame? This is where things get tricky. The preponderance of opinion on the matter, is that most of the blame falls squarely on the doctors. Why is that you may ask? Well as I said before, roughly 90% of that spending requires the authorization of your doctor in one way or another, so it's easy to lay blame there. But of course, that is pure propaganda and misdirection from the real truth of the matter. The fact is that the medical industrial complex wants you to believe that doctors are the problem. They also want you to believe that doctors are wealthy and arrogant, and that the only way to control health care costs is to own them, and control them to their own advantage. The thing is, the public is buying into that propaganda. So lets explore this assertion.
First, lets really look at how much doctors get out of that 18% of GDP pie. You may be surprised to find that the physician piece of it is shrinking steadily. One trick of accounting is that they love to lump all of the doctors in with the rest of the "providers". But doctors take the blame, so let's look closely at the numbers, but just for doctors. There are about 800,000 MD's and DO's (full time equivalents) practicing in America today. These are the "real doctors" you hear about. You know, the Mercedes driving, golf clubs in the trunk, Country Club going types you always hear about. This gang makes (on average) $200,000 in gross wages, and $50,000 in benefits yearly. If you multiply $250,000 by 800,000, you see that all of the real doctors garner about $200 billion. Not bad, but when you divide that by the $2.7 trillion in total health care spending annually, you find that it amounts to a whopping 7.4 pennies on the dollar. That's right, less than 7.5 cents of your health care dollar goes to the real doctors. And, it is less and less every year. Physician wages are a deflationary part of the overall health care cost crisis, so in that sense, we are already doing our part to solve the problem.
The next thing you hear about, is that doctors practice in a way that over-treats patients. The data for this is based on regional variations in the numbers and types of expensive tests and procedures. But that data is extremely biased and flawed because it is based on availability, not on the validity of the treatment. If you have an arthritic hip, and a good hip replacement surgeon is available locally, you are more likely to have it done, rather than continue to take pain medicine. It's a quality of life decision. It doesn't mean the treatment is inappropriate. Besides, it's the patient that makes the decision. The doctor just offers the treatment. So who is to blame?
I've heard it said again and again, that doctors should not be paid fee-for-service. Fine, but will that make any difference in costs over time? No. Back in 1980 the vast majority of doctors were paid fee-for-service and, as noted, health care costs were half of what they are now, as a percentage of GDP. Also, if you look at a mature managed care system like Kaiser Permanente, where the physicians are paid a salary, and there is no incentive whatsoever for them to treat, or test patients excessively, you will find that their insurance premium costs are no lower than the competition. Further, they do it with the lowest administrative fees of any health care organization in the country, spending only 5% of the premium dollar on paperwork, and 95% on actual health care for their members. If putting all of your doctors on salary led to lower utilization and lower costs, the entire health care system would be one big Kaiser Permanente by now, because nobody would be able to compete. Obviously this has not happened, and that is because what you are hearing about doctors being the culprits, simply isn't true.
Doctors are the scapegoats in all of this, and we also are the target of a smear campaign by the true perpetrators of this economic disaster that is the US health care system. Doctors put patients ahead of politics, and try to rise above vitriol. It is more from the lack of guidance by physicians, that we are in the situation we are in. If you want to fault the physicians, fault them for being silent for too long, and for allowing themselves to be gagged by signing employment contracts that won't let them speak out about the real cause of runaway health care cost inflation.
No, physicians are not blameless, but their shrinking piece of the action speaks volumes about whom is really profiting from all of this.
Friday, March 21, 2008
On Physician Ethics and Professionalism
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)
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)
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.
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