Photo Credit: Andy Dean Photography/ Shutterstock.com
May 13, 2013
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One of the most effective scare techniques employed to preserve our
grotesquely inefficient, overpriced health care system has been to
invoke the red peril of “socialized medicine”. Never mind that
foreigners in advanced economies fail to recognize the caricatures
scaremongers supply, or that Americans who need emergency care while
overseas are almost without exception impressed with the caliber of care
and astonished by the low (sometimes no) cost to them. After all,
Americans live in the best of all possible worlds, and consumer and
business freedom are always better.
In fact, business freedom here
increasingly means the God-given right to exploit the vulnerability of
the public. The example slouching into view is more corporate control
over the practice of medicine. And based on the previews, it will make
the horrors falsely attributed to socialized medicine look pale.
Two accounts last week bring the issue home. The first came in the
Health Care Renewal blog
(hat tip Lysa). It’s a reminder of how the current institutional
efforts to regiment doctors undermine the caliber of medical care. It
has become distressingly common for HMOs and other medical enterprises
to have business-school trained managers putting factory-style
production parameters on doctor visits. Outside of foreclosure mills,
it’s hard to find similar approaches in other professions.
The
post describes how a pediatrician, Pauline, who has developed a
reputation for treating chronic conditions is at loggerheads with her
for-profit practice. The suits don’t like her patient mix. She gets too
many tough cases, when they’d rather have basically healthy kids who are
there for a cold or ear infection. Mind you, this is only partly a
money issue. These visits can be “up coded” so as to get larger
insurance/patient payments, but she gets a higher level of patients in
less-generous state insurance programs. But some of the pushback is that
her practice is perceived as disruptive, since she uses what is
perceived as too much of her and staff time, separate and apart from the
economics. She’s constantly breaking management’s precious guidelines.
One of her turf struggles:
She had set up a visit to
see a new medically complex patient and had blocked off 40 minutes, the
amount of time she felt she needed to do a good job. The child had a
complex genetic disorder, cerebral palsy, and heart, lung, and kidney
problems. Both the cardiologist and the nephrologist had called asking
her to take this patient. She agreed. After she had scheduled the visit,
a manager called her and told her that she was being allowed only 15
minutes to see that patient. After some fruitless discussion with him,
Pauline finally said, “Okay, I guess that means that you’ll be seeing
the patient instead of me, right?” The shocked voice at the other end of
the phone line replied, “What do you mean? I don’t know how to take
care of patients.” “That’s exactly my point,” Pauline put in.
Pauline
explained that this manager assigned to her office is not even a
college graduate. Physicians cannot access the schedule electronically
and have no control over scheduling. These functions are controlled by
the office manager and (amazingly) by some of the medical assistants who
have received some “leadership” training. These medical assistants are
even allowed to evaluate the clinical competency and skills of the
physicians.
And to add insult to injury, how long did
this discussion take? All those minutes the doctor spent fighting with a
petty bureaucrat come at the expense of patient care.
As an
aside, it’s hard to stress enough that this sort of demoralizing
micromanagement and unwillingness to listen to and learn from workers,
is a widespread shortcoming of management American-style. And it has
weirdly been airbrushed out of the media. When I was a kid in business
school, US manufacturers were having their clocks cleaned by Germans and
the Japanese. There was a good deal of critical self examination back
then. One source of foreign ascendancy was that they had newer
factories, so you couldn’t really blame American management for that
one. But the second was that it was widely acknowledged that US managers
were generally poor at dealing with labor. And this wasn’t “labor” in
the union sense, but at having productive relationships with factory
workers (note that there has been massive revisionist history since
then. When I was in Bschool, none of my classmates, nearly half of whom
had worked in major manufacturing companies, had bad things to say about
unions.) Now you’ll often see the decline of American manufacturing
attributed to unions in an “everybody knows that” tone.
Now before you come running to the defense of management against the doctor, think twice:
So
let me add a further nugget about Pauline’s background. In one of her
previous jobs, she was made the manager of a pediatric outpatient center
within a county hospital caring for a largely indigent population. This
center had been running in the red for a good while. Pauline took over
and within 28 months she’d streamlined the place and had them running
well in the black, while still administering a quality of care that
Pauline and her colleagues could be proud of. In short, Pauline could
probably tell the managers of her current practice a thing or two about
how to optimize patient scheduling without compromising care or cost —if
they’d listen.
As bad as that is, most patients are
unware of how much their care has been fitted to a Procrustean bed. The
deliberate degradation in the name of profits is going to become more
obvious, at least if the health care industry has its way.
I strongly encourage you to read
this post
from Whole Health Chicago (hat tip Lambert) in full. It shows how the
future of American medicine is to fire the ones who are unhealthy. No, I
am not making that up. The writer, Dr. David Edelberg, describes a
recent presentation by a large insurance company. They’ve apparently
been hosting similar sessions with physicians in the Chicago area in
large medical practices. Here are the key bits (emphasis original):
The
speaker at these evenings is always a physician employed by the
insurance company. His/her title is medical director (I begin to think
there must be dozens and dozens on their payroll) and he always begins
by reassuring the audience that he was in clinical practice himself so
he understands something of what physicians–especially primary
care physicians–are facing. I view this physician more as a “Judas
steer,” the animal that leads an innocent but doomed herd of cattle
through the slaughterhouse corridors to the killing floor.
• The
health industry hopes that individual medical practices and small
medical groups will ultimately disappear from the landscape by being
financially absorbed into larger groups owned by hospital systems.
And
why do the powers that be regard this as desirable? Although the
article does not stress this point, doctors have an established revenue
stream. So the acquirers buy them out and impose discipline on those
artistic, freewheeling doctors. The “practice style,” which used to mean
the independence that doctors once enjoyed, is now an Orwellianism and
includes hewing to corporate guidelines as to how to operate.
And here’s what to expect:
Physicians
are expected to spend a limited amount of time with each patient, and
are encouraged to see as many patients as possible during a workday. The
insurance companies, sometimes with the token cooperation of a few
physician-employees, create vast books of patient-care guidelines to
which they believe their physicians must be “accountable” (remember this
word, it will crop up again). These guidelines might mean documented
Pap smear and mammogram frequency, weight management and exercise,
colonoscopies for patients over 50, and getting that evil LDL (bad
cholesterol) below 99 by any means possible…
If the chart audit
system discovers that a physician, for whatever reason, is an
“outlier”–that she’s either not following the guidelines exactly or not
getting the results anticipated for her patient population—she’ll be
financially penalized. A quick example of what might occur: if your LDL
is 115, you may be on the receiving end of a statin sales pitch from
your doctor, not because bringing it down to 99 will improve your
longevity, but because your refusal to do so will impact her financial
bottom line.
Now of course, you might say, “Well, in
fairness, medicine is too much of a cottage industry. Look at how many
doctors give unnecessary annual EKGs to patients in low risk groups. How
else are we going to get to evidence-based medicine?” The problem is
that what we as patients will get isn’t driven by best outcomes, it’s
driven by profits. Edelberg explains:
…the subtext of
“standardized” always includes the unspoken “spend less money on the
patient.” Thus, a doctor might be financially penalized for recommending
nutritional counseling to lower cholesterol (“counseling is expensive”)
instead of writing a generic statin drug (cheap). Or recommending
psychotherapy (“therapy is very expensive”) instead of generic Prozac
(cheaper than M&M’s). Or referring patients for massage,
acupuncture, or even chiropractic (“expensive, expensive, expensive!”)
instead of pushing an over-the-counter antiinflammatory (free to the
insurance company, as it’s OTC).
And I shudder to
think what becomes of patients who don’t hew to standard templates: the
person who had a high body mass but not due to dangerous abdominal fat
(which is what creates the health risk) who is pushed to take the
latest, greatest diet drug. What about people who don’t buy into the
religion of getting your LDL down to below 100 (one reader argued that
while it may lower your risk of heart disease, it increases your
all-factor death risk by reducing your ability to fight MRSA)? Will they
face penalties if they fail to comply?
No, you just will find it nearly impossible to get a doctor to take you:
• Let me close with a best-as-I-recall quote from an insurance company medical director.
“We can no longer afford to pay for health care under the PPO model.
Our plan is to phase out all fee-for-service care during the next few
years. We’ll pay you doctors a finite amount of money to take care of a
defined population. We tell doctors, ‘Don’t spend much money and you can
keep the difference. Period. Don’t follow guidelines, and you’ll be
leaving behind some serious money on the table and we’ll just take it
back.’”
In case you think I overstated the implications, Edelberg recapped the discussion that ensued:
One
physician piped up…. “But what about the non-compliant patients who
won’t take the meds, don’t eat well, don’t have mammograms, continue to
smoke? And what about super-health-conscious patients who want their
vitamin levels measured and want referrals to acupuncturists?”
Another
physician answered wearily for the medical director (who didn’t
disagree): “You’ve got to fire patients like that. Get the non-compliant
and the super-demanding out of your system. They’ll drag your numbers
down. Hit your personal bottom line.”
Hey you, patient. Yes, I
mean YOU. Pink slip time! Canned! Take your medical records and don’t
let the frosted glass door hit you in the…on the way out.
In
other words, if you are high maintenance because you don’t do what your
doctor says (and remember, “non-compliant” includes people who don’t
follow orders because they think the cookie-cutter approach isn’t right
for them) or want higher service or per the example of the pediatrician
Patricia’s 40 minute case, have a complicated set of ailments, you’ll be
shunted. The brave new world of corporate medicine will eject you.
The
rich are unlikely even to know that this change is occurring. There
will be a tier of doctors on the high end to cater to patients who want
more personalized, cutting edge treatment and might need some prodding.
And they can always go abroad if they can’t find what they need here.
But for ordinary schlubs, expect to find the doctor’s office become more
hostile as the brave new world of corporatized medicine becomes
entrenched.
Yves Smith is the founder of
Naked Capitalism and the author of 'ECONned: How Unenlightened Self
Interest Undermined Democracy and Corrupted Capitalism.'
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