Doctor is a word that historically is synonymous with Hippocrates, Caduceus, men in long white coats and an evolving field of new wonders. Today people fear the profession for the financial costs and distrust of the industry, but do so with respect for practitioners who went through 4 years of college, 4 years of medical school and up to 10 years of residency just to be able to provide specialized care. Though still greatly appreciated by patients, the relationship has eroded over time to a point that physicians nowadays could call their patients customers. I will explain why and how medicine is no longer in the control of the people and healthcare with the help of the Affordable Care Act (Obamacare/ACA), Tea Party, and health insurance companies cannot work to benefit the people. The problem is threefold and in the end patients will be the ones to pay for it.
Business Models
The number one reason most physicians joined the exclusive profession of as a Medical Doctor (M.D.) or Doctor of Osteopathic Medicine (D.O.) is to help people. The downside of this is that sacrifices must be made in order to provide our services. These sacrifices as with a lot of professional jobs require additional years of schooling, increased personal stress, a substantial financial debt, increased time to marriage, less time home with family members and a high suicide rate. This dedication and time has also lead to an unforeseen problem, and that is the business of medicine being taken care of by someone other than the doctor. During the Nixon Administration, at the behest of Kaiser Permanente’s Founder, the great HMOs came into existence and the decline in health care began. As a fan of capitalism I believe in the ability of private and public shared entities to make their shareholders the most amount of profit possible. In the past couple of years health insurance companies have seen greater than 20% increase in their profit margin. These companies make money solely if they can claim more than they spend, with the profit margin going to shareholders, bonuses and into new funds to help fight legislation they see as a threat to their profits.
This story and tale has been said many times, but how does it affect your physician? First and foremost if the goal is to make money, a company should find ways to not spend money while getting the most amount of benefit. Here in lies the billing structure of today. There are many crafty ways in which your doctor can perform services and insurance companies can try and not pay us for these services. An industry of coders on both sides of the row now exist, documentation far more important than time consumed seeing patients, and the turnaround time in some cases is up to 90 days. A pregnant woman may see her doctor three times before being paid for the first visit, and if there is something in the documentation the insurance company does not like, well that can delay the process even longer. This burden has made it easier for hospital systems to buy up small offices as they cannot afford the staff needed just from the billing aspects to keep a practice running. By creating a higher barrier to entry or to maintain their business, the American Hospital Association (AHA) and Private Health Insurance companies have waged a war against each other, where administrators win and consumers and the workers that actually see the patient lose.
Barrier to Entry
Let us understand how physicians have lost the way and were taken over so easily by the administrative world. As I stated earlier, those in medicine go through a tremendous amount of schooling to learn how to take care of their patients with little desire to learn about the business side of the field. They naively assumed that their valued care giving would be compensated. Flattery, arrogance and a false sense of altruism have been a great downfall to the profession as well. If someone were to get in any legal trouble, they would immediately call a lawyer, and when physicians are being told that some sort of change is beneficial overall, a private consultant who is a J.D. /M.B.A. should be consulted. Why? Because doctors and are not capable of understanding savvy or cunning language that is used to allow someone else to make us work longer hours, produce more work or see additional patients for the same price or more. This can be done at various levels, from hospital wide policies that create new rules that make physicians answer countless emails for free or reduce benefits such as a hospital lunch of soup and salad deemed too costly for the hospital to maintain. All of this is done underneath the guise of increased patient care and hospital proficiency. A simple change as not providing a soup and salad, however, can create a non-charitable loss in hospital morality and increase segregation of physicians of various practices who will not intermingle as before.
This is what can hurt physicians in the hospital, but what about while they are in medical school? A medical student in four years can be required to pay or obtain a loan for the sum of $150,000 to $200,000 for the total time of their education. Undergraduate and Graduate school educations are on the rise, but what about the USMLE, the organization that charges for STEP 1, STEP 2 CK & CS and STEP 3 tests that doctors must take? STEP 1 is comprised of Basic Science classes that for those not going into research are foundational, and costs $550+ to take the computerized exam. STEP 2 has two parts, the computerized question format which asks clinical questions and costs an additional $550+. I am not dumbing this down, but the english practice portion that was initially only for international students costs $1,200+. This exam for foreign graduates had a pass rate of 77% in 2011 and the pass rate for US students is 95%. This test was not always required of U.S. graduates, but when the pool of 2,000 plus students paying over $1,200 a person to take the exam was taken into account, it was an easy choice for National Board of Medical Examiners (NBME) to make. The end result is money from the masses to fill a few pockets. Charging a one time fee to take an exam such as the Bar Exam that lawyers take would reduce the cost of medical school and would still ensure a physician is qualified to take care of your needs.
Physicians are proud people, but pride often comes with foolish admirations and goals that make people lose sight of what is important. Previously living in Washington DC, I learned about the many different associations that exist in the medical field. The relatively small field of Physical Medicine and Rehabilitation has 3 different organizations: the AAPMR, AAP and the ABPMR. Each of them claim their value from Board Certification exams that are $3,000+ and have never been proven to produce a higher quality practitioner when compared to Uncertified Physicans. Aside from these physician created organizations, there are also lobbying groups that are aimed at going to Washington DC and fighting for “our rights.” Per a lobbyist, the various organizations won’t even work with one another. Surgical groups feel as if their cries are more valid than internist problems and issues and psychiatry groups think their special circumstances outweigh the problems of emergency physicians. This profession has inherently decided to try and divide and then conquer while the American Hospital Administration (AHA) has always had one voice.
As reported in the Times Magazine, the AHA has outspent the defense industry over the past several years. One of the provisions they were able to get included in the ACA was to make sure that Medicare and Medicaid finances would not be given to a hospital that has physicians investing in that hospital. Therefore a Cooperative Hospital , where the ratio of income from CEO to janitor is the lowest, waste is reduced and each employee has a vested interest in the competitiveness and efficiency of the company, would not be able to receive reimbursements.
Another ingenious trick that has been used for some time to promote Health Insurance, but helps keep physicians at odds with each other, centers around billing practices. As the Times article referred to above noted, each hospital can bill at different rates for the same service being provided, and insurers from Medicare/Medicaid to Private Health Insurances pay a portion of this allotment requested. Every time a customer receives a bill, they see the hospital/physician requested amount, the amount the insurance company has agreed upon, and the amount they are paying based on your deductible and percent coverage. This only will provide a fodder to feed the fire of insurance companies and show practitioners as overbilling thieves. In this case the field has unwittingly been divided and conquered.
So what’s the Solution?
I started writing my blogs to present a view that would be positive, informative and hopefully shed a light on the humanity of the world. The good news is that physicians and medical students alike still care about patients and want to spend their time taking care of them, and answering phone calls and emails as they are able to without adversely affecting their time to spend with their family members. Working a little overtime and getting in early to get things done is part of our hard work ethic and long years of studying, but these compassionate traits were seen as weaknesses and were capitalized upon. The SGR fights with congress, to Centers for Medicare & Medicaid Services (CMS) systematical reduction of payments for procedures that physicians perform does not promote patient care. Physicians historically and currently want to be the voice of their patients and do whatever is right to help them out. Doctors for the most part do not understand business well, are not cunning, and prefer not to waste time on anything apart from what they have been trained to do. The field is here because to help people, but because these interests do not make companies money and doctors have a hard time understanding why someone will not pay them for what they did, it remains an uphill battle. The savvy ones are able to find some loop holes that allow them to continue making money with a reduced level of stress, but the majority of physicians want to simply help everyone out and do what’s best for you. Our healthcare system where patients face high premiums, outrageous deductibles that are hard to reach unless something catastrophic affects us, and physicians that spend more time with paperwork than with patients is not sustainable. The only hope is for people to simply say no more, and to reject our current system and ask for a new one, but if history has taught us anything this will not happen in my lifetime. The only other solution is to give this current system a heavy enough push that a revolt in the other direction is the only thing possible.
As the late Nelson Mandela said, "A good head and a good heart are always a formidable combination." I only hope we have someone who is of this caliber to help with an issue that in the end is to the benefit of the people.
Till Then.
