The Business of Medicine
The physician-patient relationship is a good example of the influence of business on the profession of medicine. Most people want their doctor to understand a little of who they are, what they need, care about their best interests, and to give advice based on the best and most current medical information. Some of this has been lost in the age of technology when physicians become technicians. I didn't understand this until I talked to a gastroenterologist after the patient's insurance company justifiably refused to pay for a colonoscopy because he had just one. When I asked the GI doctor about this, he said he was just doing what the general practitioner requested. So I asked if he took a history and he said "No, I'm just the technician." My gastroenterologist isn't this impersonal and most physicians aren't. However, some are. Recently I accompanied my wife to see an orthopedist for her shoulder pain. The office was an assembly line. We went from the window where we checked in to the person who insured she was insured and would guarantee to pay if insurance did not, to a radiology technician who insisted that the doctor wanted his 'own set of x-rays' even though Mary had just had x-rays in the hospital, to a pair of physician's assistants who looked at the history forms Mary had filled out and asked a couple questions in a way that suggested the answers, and finally to a physician who was accompanied by a scribe and someone else. After a quick physical exam that related to her shoulder only he pronounced his diagnosis and the treatment recommendations and left the room. There was not time for a discussion of alternatives, side effects of the various treatments, or any hint of sympathy for the impact her very painful condition. For many people the knowledgable, friendly, never-too-busy, family practitioner is a distant myth.
The orthopedist's office was an extreme example of the influence of business on medicine. This orthopedist office did their own x-rays (which they insisted on doing even though my wife had just had one - I should have objected), their own MRI scanner, operating suites, and physical therapists. Do you remember when physician got censored for owning their own pharmacies where they directed patients for medication and over-charged? This orthopedist's office was far more sophisticated and, I suspect, far more income producing. Many cancer clinics often own their own PET scanners and self refer for scans that are very expensive and ofter un-needed. There are many other examples of this over-testing to increase profits.
Please understand that most physicians (and I am talking about MDs and DOs) are really concerned about the welfare of their patients and are trying to do the right thing as a professional. But the bean-counters, the MBAs, are trying to commodify the relationship between physician and patient. If your doctor works for a clinic owned by a hospital or a large managed practice, the clinic administrator wants your doctor to see a patient every 15 minutes. He also wants your doctor to use the hospital lab for blood tests, x-rays and physical therapy, even if those services are not as good or more expensive than non-allied services. And the bean-counters are watching. They use the electronic medical record, the new standard for physicians, to extract data about the number of encounters between physician and patient per hour, whether the co-payment has been collected, how long each encounter with a patient takes and how much lab and x-ray each physician orders. The electronic medical record has been touted to be necessary for clarity of recording the patient/physician encounter so that the next doctor who sees you will know exactly what is going on and not have to try and decipher illegible handwriting. However, its alternative purpose is to give the business people data. If a health care provider underproduces, meaning is not generating a large enough income, they are gently reminded that they are not working as hard as their partners. In the ER we used to keep track of how many patient's each of us saw per shift. One of our partners, and one of the best physicians, saw the fewest. Someone has to be the slowest, by the way. But it was never a problem and never even brought up because he always did a great job.
Physician need help with the business of medicine because each insurance company has different requirements for billing. Two 700 bed hospitals were compared; one in Canada with its single-payer system and one in the US. In the Canadian hospital there were 7 people in the billing department and in the American hospital there were 700. One more thing about insurance companies - this should be another blog - but they only care about the volume of claims coming through them because they take a percentage. They do not care whether a procedure is medical correct even though they pretend to. To be more specific, the minions care, the nurses who review claims, they care. But the big boys and girls, only care about stripping their 25% off the top of the health care dollar (compared to 4% by Medicare). One insurance executive annual bonus was more than I made in my entire career as a physician. The help physician have received navigating these turbulent financial waters has resulted in them losing control of their craft, in more ways than one.
In 1999 Dr. Bernard Lown wrote the book The Lost Art of Healing in which he talks about the physician patient relationship in detail and gives many examples. Dr. Lown won the Nobel Peace prize for his participation with International Physicians for the Prevention of Nuclear War. He also invented the DC defibrillator, was instrumental in starting cardiac intensive care units and many other parts of modern cardiac medicine. This book looks at how physicians and patients interact and how a knowledge of the patient obtained through taking a thorough history and doing a physical exam, relates to making a correct diagnosis and subsequent treatment. It also addresses the complexities of the human mind and how it influences the physical manifestations of disease.
If you are interested in how medicine became a business read Elizabeth Rosenthal's book An American Sickness. I contributed a few interviews for the book and she used my experiences at Providence Medical Center in Portland, Oregon as an example of a system that went from a non-profit hospital with a goal of helping the poor to a giant corporation with its own hedge fund. Dr. Rosenthal was a reporter for the NYTs and is now editor-in-chief of Kaiser Health News.
The orthopedist's office was an extreme example of the influence of business on medicine. This orthopedist office did their own x-rays (which they insisted on doing even though my wife had just had one - I should have objected), their own MRI scanner, operating suites, and physical therapists. Do you remember when physician got censored for owning their own pharmacies where they directed patients for medication and over-charged? This orthopedist's office was far more sophisticated and, I suspect, far more income producing. Many cancer clinics often own their own PET scanners and self refer for scans that are very expensive and ofter un-needed. There are many other examples of this over-testing to increase profits.
Please understand that most physicians (and I am talking about MDs and DOs) are really concerned about the welfare of their patients and are trying to do the right thing as a professional. But the bean-counters, the MBAs, are trying to commodify the relationship between physician and patient. If your doctor works for a clinic owned by a hospital or a large managed practice, the clinic administrator wants your doctor to see a patient every 15 minutes. He also wants your doctor to use the hospital lab for blood tests, x-rays and physical therapy, even if those services are not as good or more expensive than non-allied services. And the bean-counters are watching. They use the electronic medical record, the new standard for physicians, to extract data about the number of encounters between physician and patient per hour, whether the co-payment has been collected, how long each encounter with a patient takes and how much lab and x-ray each physician orders. The electronic medical record has been touted to be necessary for clarity of recording the patient/physician encounter so that the next doctor who sees you will know exactly what is going on and not have to try and decipher illegible handwriting. However, its alternative purpose is to give the business people data. If a health care provider underproduces, meaning is not generating a large enough income, they are gently reminded that they are not working as hard as their partners. In the ER we used to keep track of how many patient's each of us saw per shift. One of our partners, and one of the best physicians, saw the fewest. Someone has to be the slowest, by the way. But it was never a problem and never even brought up because he always did a great job.
Physician need help with the business of medicine because each insurance company has different requirements for billing. Two 700 bed hospitals were compared; one in Canada with its single-payer system and one in the US. In the Canadian hospital there were 7 people in the billing department and in the American hospital there were 700. One more thing about insurance companies - this should be another blog - but they only care about the volume of claims coming through them because they take a percentage. They do not care whether a procedure is medical correct even though they pretend to. To be more specific, the minions care, the nurses who review claims, they care. But the big boys and girls, only care about stripping their 25% off the top of the health care dollar (compared to 4% by Medicare). One insurance executive annual bonus was more than I made in my entire career as a physician. The help physician have received navigating these turbulent financial waters has resulted in them losing control of their craft, in more ways than one.
In 1999 Dr. Bernard Lown wrote the book The Lost Art of Healing in which he talks about the physician patient relationship in detail and gives many examples. Dr. Lown won the Nobel Peace prize for his participation with International Physicians for the Prevention of Nuclear War. He also invented the DC defibrillator, was instrumental in starting cardiac intensive care units and many other parts of modern cardiac medicine. This book looks at how physicians and patients interact and how a knowledge of the patient obtained through taking a thorough history and doing a physical exam, relates to making a correct diagnosis and subsequent treatment. It also addresses the complexities of the human mind and how it influences the physical manifestations of disease.
If you are interested in how medicine became a business read Elizabeth Rosenthal's book An American Sickness. I contributed a few interviews for the book and she used my experiences at Providence Medical Center in Portland, Oregon as an example of a system that went from a non-profit hospital with a goal of helping the poor to a giant corporation with its own hedge fund. Dr. Rosenthal was a reporter for the NYTs and is now editor-in-chief of Kaiser Health News.
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