It’s Time for Doctors to Reclaim Ownership of Their Profession

We can’t sustain rising healthcare costs and, more urgently, we can’t sustain the aftershocks of a healthcare bubble bursting
October 13, 2010 -- When I was seven, I loved getting 25 cents from my Sunday school teacher for participating that day. I’d head to the variety dime store, giddy that I could buy candies on the sly without my mother’s warnings about getting fat. Even so, in 1965, obesity wasn’t such a big problem for me or the other kids where I grew up in rural Illinois.
 
I don’t think it’s a coincidence that obesity took off in the 1980s. Children were fair game for advertisers. Aggressive marketing unleashed all forms of predatory capitalism. At that time, I was too busy to notice, burning the midnight oil in medical school and residency; and I was certainly too naïve to fathom how these same forces would upend my career and our economy.
 
Capitalism depends on consumerism as surely as fire needs oxygen. When healthcare costs surged in the mid 1980s, insurance companies failed to rein them in with managed care because consumers and doctors rejected the administrative interference. And there was money to be made. Indeed, for decades, physicians have been like kids in a candy store ordering tests and procedures with total abandon and with constant rationalization that this was always for the benefit of the patient.
 
“Cost sharing” became the new deterrent. Denied services, co-pays, deductibles and unpredictable co-insurance drove even insured families into medical bankruptcy. Shouldn’t we have become suspicious about “consumer-driven” market reforms that spawned catastrophic healthcare policies?
 
Rest assured the Oregon Health Care Quality Corporation promises to “help doctors, hospitals, insurers, providers, purchasers, government agencies and consumers work together to accomplish what they cannot do alone.” Click on the PricePoint System to hospital shop. And there’s more: the Healthcare Cost and Utilization Project (HCUP), The Leapfrog Group, the National Healthcare Quality Report and Hospital Compare—all at our fingertips.
 
What harm could that create?
 
It must be understood that doctors no longer own their own shingle. When post-World War II America ceded healthcare to employers, insurance companies inherited a cash cow. Individuals, families and businesses now realize that insurance companies cannot deliver a product that can be consumed for their benefit when profits are involved. The conundrum is very basic. Health is a societal investment and not a commodity that can be consumed and marketed as healthcare. For-profit healthcare creates perverse incentives for those who profit from the unhealthy and the worried well.
 
Employers, tired of insurance companies profiting from their employees, are marketing a new paradigm of managed care through self-insuring. Consumers should be wary of “roadmaps” for employer health management and value-based benefit designs. Values will be compromised for the sake of value.
 
Market-based healthcare demoralizes the doctor. I left my career as an internist and endocrinologist over ten years ago, when I was at my prime. My integrity was too compromised by the compromises the market demanded of me. Many of my physician friends envy my good fortune married to a radiologist who gives me that choice. But I still mourn the loss of my career—especially since I know there are critical needs for primary care doctors.
 
Market-based health care won’t work. Quality healthcare depends on a trusting relationship between the doctor and patient, an art that that is unquantifiable. Yet we’re reassured that healthcare reforms will be evidence-based. Even a spoonful of sugar doesn’t help swallow “evidence-based” research cooked by PhRMA and medical device companies. Healthcare reforms were adopted from the evidence-based playbooks of No Child Left Behind. I assure you doctors will be treating to the HEDIS test. This approach is impersonal and non-specific.
 
Increasing technology inserts more impersonal care outcomes. The keyboard is touched far more than the patient. I may sound quaint when I complain about vital signs done by machines. But the touch of a radial pulse would have picked up the irregularly irregular rhythm of my mother’s heartbeat, which blossomed as rapid atrial fibrillation in the emergency room. A doctor skilled in even the most rudimentary aspects of the physical exam can rapidly discern abnormal from normal. The doctor’s touch connects and reaffirms trust.
 
In defense of unbridled testing, doctors demand tort reform. Expediency is the bigger reason. It’s been easier for physicians to go along to get along when consumers Google their symptoms and bring their assessments to the clinic. Yet there are false negative tests that wrongly reassure; and there are false positive tests that, at minimum, create anxiety. The false positive tests create a domino affect of more tests, treatments, drugs, adverse reactions and even death -- all with cost.
 
Why did this happen?
 
Doctors became pawns of predatory capitalism, pawns of a market that was driven by bottom-line financiers. Without price tags, physician services are literally priceless. This is not a good scenario when cutting-edge procedures and drugs are commercialized and capitalized by profiteers, creating an artificial demand. Both doctors and patients argue that innovation would be otherwise hampered from “rationing” if protocols guide practices. They magically delude themselves into believing that pricey healthcare is “free” for the insured.
 
We already have rationed care. The question is who should who should determine how we ration care: doctors or employers and insurance companies?
 
Doctors must reclaim ownership of their profession and demand full transparency of healthcare costs. They’ll better grasp the inherent inequities that arise from the multiple payers and deniers of employer-based healthcare. In doing so, doctors can reassert true value to the care they give and to healthy values we, as patients, must embrace. We can’t sustain rising healthcare costs and, more urgently, we can’t sustain the aftershocks of a healthcare bubble bursting.
 

Dr. Kris Alman retired from healthcare to become a citizen activist for a healthier democracy. She advocates for fair taxation to invest in our common goods--prioritizing education, renewable energy, campaign finance and healthcare policies and laws.

 

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Comments

Kris, your description of yourself is so right on, this is the Kris I know: Dr. Kris Alman retired from healthcare to become a citizen activist for a healthier democracy. She advocates for fair taxation to invest in our common goods--prioritizing education, renewable energy, campaign finance and healthcare policies and laws. Jody

So, what's your point? Evil insurers and technology are getting between you and the patient? I'm sure there are free clinics that would love to have your services, and patients there who need you. Agreed, insurance reimbursement on FFS basis inadvertently created a monster: doctors and hospitals who fixate on procedures because that's how they get paid. But your former profession can't seem to agree on any other way to get paid -- they fight quality measures and evidence-based medicine as "cookbook" medicine....well, then write the cookbook yourselves! And be well prepared with fact-based reasons for deviating from the recipe. Why is that so hard for those who brag/complain about their 7+ years of post-grad education? Here's your other option: go bare. That's right, don't even take insurance. See how much your services are worth in a market where people don't want to pay the equivalent of a pizza every week for health insurance coverage. http://bit.ly/a2ux0L See how much you like having this conversation with every patient: How much is that? Is there a cheaper way to do that? Doctors and patients have no idea what the real cost of care is, and they can thank/blame/damn insurance for that. That's the real problem that needs to be reformed. There's the reason for this saying: The most expensive piece of medical equipment is the doctor's pen. You want the Marcus Welby days? then we go back to straight 80-20 insurance policies for catastrophic care, and the annual physical and routine visits and all that "preventive" care (ie tests that somebody makes money on) come out of pocket and you don't have state mandates telling you to pay for maternity coverage when you're post-menopausal. Good luck with that!

There has always been solid evidence to support the critical role of the independent practice of medicine - or at least viable choices - to enable the sustainable delivery of quality healthcare. If we would look at areas where the physicians/providers are primarily independent, we would see OHP success stories and the fact that we've 'bent' the cost curve and enabled access to quality healthcare, despite the dilution caused by aggregation with hospitals and their employed providers - i.e. their much higher utilization & cost without ensuring quality to the patient. An acute, hospital-centered approach without servant, participatory leadership and fierce governance needs to be kept honest by the community and/or competition. Unfortunately there is no shortage of disconnected board members and hospital leaders who are quite happy with their personal benefit, the status quo.

Dr. Altman makes many good points and we should all take heed. A factor not mentioned is the decline in medical school applications by individuals who want to serve society while making a comfortable living. The competition for the ROAD subspecialties (radiology, opthalmology, anedthesiology, and dermatilogy) tells another aspect of Dr. Altman's story. Too many young aspirants to a medical career follow the money and seek high-paying relaxed lifestyle jobs within medicine. And those that preceded them have had more than their fair share of votes on the committees where reimbursements are negotiated. The profession and the public all lose. F. Matthies

Perhaps what everyone should heed is that just about all health care is financed with "other peoples' money (OPM), a financing structure that woulld threaten the value of any market segment. Our culture almost across the board seems deeply offended when cost raises its head as a factor threatening to influence the ebb and flow of where and when patients seek care. The totally unjustified variations in health care service delivery have been documented repeatedly for decades. I would suggest if you asked knowledgeable folks involved in the economics of health care whether they held hopes for evidence based medicine as a high probability leverage point in controlling costs, most would reject the proposition. "Trust me" is code for let me do what I want, when I want, and please do not obstruct those decisions whether patient, insurer, govt, or employer. It is hard to imagine how we create a "high value" health care system when so many are offended by talking costs and someone else is paying for it. The health care system is composed of many vested interests with the common aspiration of tightening control over their revenue streams and growing as economic enterprises. After all, how many hospital board of trustees are directing their managements to reduce revenues next year for the good of the community? The economics of health care are collapsing all around us Perhaps 90% of all health care cost r is driven by someone's take home pay. If costs have been rising unacceptably, someone's paycheck is reflecting that. Just about everyone gainfully employed by the US health care system is paid very well. We are probably twice as expensive as other countries because we pay twice as much.

Hey, Anonymous--it's possible to practice without any insurance contracts. I do it every day. There are enough patients out there irritated by the seven minute visit that they do seem to find the time I spend with them to be of value. Go figure! Know what? I am not alone, either. I agree with Dr. Alman that it's HIGH time for physicians to reclaim ownership of the profession--before it's too late. Our first duty is to our patients, not to bureaucracy.