Friday, November 18, 2011

Lamenting the Demise of Medicine in America

Two physicians from Beth Israel Deaconess Medical Center, Pamela Hartzband, MD and Jerome Groopman MD, write in the Oct. 13 edition of the New England Journal of Medicine that medicine has become industrialized. In their view, the medical exam given by a doctor to his patient has become an encounter between a provider and a consumer. Their lament is correct but a little late in coming. When I was working on my MBA, I researched the business of medicine and discovered that the process that these physicians lament has occurred over the past 6 decades. The insurance structure that exists today came about as a result of wage freezes during World War II.

As employer-sponsored health insurance become more popular, the revenue cycle of medical care changed. Instead of the patient paying for the entire service at the time of treatment, the patient would pay a small amount of the medical bill and the insurance would pay the rest.

And then:
…insured patients began to request that the [medical offices] bill their health insurance before making payments on their accounts. [The patient] agreed to pay the balance due after the carriers determined the insurance portion of the claim. Each insurance company had a unique set of billing requirements. The complexity of the new billing procedures greatly increased paperwork and practices had to, therefore, increase the size of their billing staff [or add a billing staff which had heretofore never existed in the medical practice]
These changes dramatically affected how Americans viewed health care. First, by not paying the premium, they no longer had the knowledge of the true cost of those premiums. Secondly, by not paying for the medical care at the time of service, they no longer had the knowledge of the true cost of health care. The organizational culture of healthcare changed and the organizational memory has been lost by the American populace.

The Deaconness folks weigh in:
“We are in the midst of an economic crisis and efforts to reform the health care system have centered on controlling spiraling costs. To that end, many economists and policy makers have proposed that patient care should be industrialized and standardized.”
Patient care became standardized when insurance companies began telling physicians how much their services are worth. No longer is a physician paid based on the financial needs of the physician’s business, but instead on a government produced fee schedule based on a formula called RVU’s. Physicians have not had a raise in their fee schedule from Medicare in over a decade, and the docs are so appreciative that each year the fee is not cut that they don't realize that they did not receive any increase.

The Deaconness Duo adds:
“The problem ... is that the special knowledge that doctors and nurses possess and use to help patients understand the reason for and remedies to their illness get lost in a system that values prepackaged, off-the-shelf solutions that substitute "evidence-based practice" for "clinical judgment."
What Hartzband and Groopman do not understand is that the patient does not want to pay for the physician to develop an evidence-based plan of care. Today’s exam averages 15 minutes. A physician cannot do the type of work that Hartzband and Groopman want in 15 minutes. That is the reason that more and more medicine is pre-packaged, and it works for the majority of the population. For the minority of patients that need the more protracted appointment and care, there is resentment that they should have to pay more for their care than someone else.

More from Boston:
“Even more troubling ... is the impact of the new vocabulary on future doctors, nurses, therapists and social workers who care for patients. Recasting their roles as providers who merely implement prefabricated practices diminishes their professionalism.

Reconfiguring medicine in economic and industrial terms is unlikely to attract creative and independent thinkers with not only expertise in science and biology but also an authentic focus on humanism and caring.”
Here, Hartzband and Groopman are correct: individuals who desire to make a contribution to society, and to be rewarded for this contribution financially, will steer away from medicine. Since insurance companies pay the inadequate physician the exact same as the extraordinary physician, what is the incentive to become a physician?

While I applaud Doctors Hartzband and Groopman for their impassioned plea to return to medicine of old, that ship has sailed. Modern medicine is dictated by a labyrinth of regulations, economics, and government oversight that has forever changed medicine in America.

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