The Doctors Club

The Doctors Club

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Vatsal Thakkar, a psychiatrist, recently wrote of the perks doctors are afforded in everyone’s favorite instrument of social justice – the New York Times. Dr. Thakkar speaks effectively and correctly about a broken health care system navigated best by pulling the ‘doctor’ card. Some on the progressive left have seized on this blatant disregard for egalitarianism as yet another example of a broken healthcare system, despite the fact that a two tiered system is exactly what they have been building over the last eight years.

flying cadeucii

To be clear, there has always been special treatment accorded fellow doctors and nurses – it has just become more obvious as the gulf between the haves and the have nots in health care has grown.  Make no mistake – this is absolutely a function of multiple strategies that have created winners and losers in the healthcare space.  The problem, of course, is that patients and physicians have ended up on the losing side of this equation.

In an effort to reign in costs, the federal government decided long ago that it was easiest go after the neighborhood private practice physicians that were practicing in that dastardly fee for service construct.  Being a small practice neighborhood physician has never been easy – it requires a special commitment to be available for your patients on a constant basis day, and night. The financial rewards were considerable, though I would argue on a per hour basis these physicians were paid at a level more consistent with electricians than hedge fund managers. As regulatory burdens increased, the amount of time spent performing non-revenue generating tasks like prior authorization reviews began to cut into physician incomes.  It started to make less and less sense to be on call for patients for 360 days of the year, and doctors began to turn to lower paying, but safer and more convenient hospital paying jobs.  While this made physicians unhappy, the real burden was borne by patients.  Instead of having a direct line to a doctor who knew you well, who would see you the same day or next day for an emergency, and then follow you into the hospital to direct your care – now you had to speak to a covering physician who didn’t know you, wasn’t invested in you, and was quick to direct you to the emergency room and hospital where yet another team of uninvested emergency medicine and hospitalist shift workers lay in wait.

Not content with the Comcast level consumer service that had now been implemented, bureaucrats next decided to curtail costs by shifting costs to consumers in the form of high deductibles and premiums in the the hope that the patient would exert downward pressure on health care costs.  That has not happened.  As Propublica reporter Charles Ornstein found out when he needed antibiotics for his son, or as journalist Steven Brill discovered when he needed emergent cardiac surgery, patients are in a poor position to negotiate prices for health care when they need it most.

In this world where risks and cost are now more than ever the patient’s to bear, is it any surprise that those with money, or influence would exert whatever levers under their control to navigate this system?

The solution from some is to no doubt provide ever more, ever better regulations, or work harder to deliver us universal health care.  The inconvenient truth the control oriented free-lunch-for-all universal healthcare proponents won’t tell you is that cost controls in this system come via rationing.  One of the indignities Dr. Thakkar speaks about in his piece is having to endure 6 weeks of back pain before insurance would approve a back MRI.  In 2010, the average wait time for an MRI in that health system beyond compare, Canada,  was up to ~12 months. There is even a helpful website you can visit that will let you know how long you can expect to wait for cancer surgery, cardiac surgery or other imaging studies.

A better solution to the current system plagued by physicians who answer first to hospital systems, insurance companies, pharmaceutical companies and regulators would be to restore the primacy of the individual beholden only to the patient: the independent physician.

<em>Anish Koka is an independent physician in Philadelphia who writes about the growing barriers between patients and physicians. Follow him on Twitter @anish_koka

 

 

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22 Comments on "The Doctors Club"


Member
Keith McCallin
Jul 22, 2016

Dr. Koka, there is a place you can go to be an independent doc and they would be glad to have you. As in genuinely happy to have a cardiologist come be part of their community.

It is a place in northeast California and the locals there call themselves the State of Jefferson. They are group that actively seeks to create a 51st state by separating north east California from the rest of the state. Tragically they have no financial good sense and no plan for sustainablity. But, their answer to fixing health care is cash on the barrel head. Then for larger medical bills, but not too large, they have a single payer system called their church.

No way would you capture the income that you would like, but model-wise, it is consistent/in the direction of what you seem to suggest. And, I bet the change would bring a boost in quality of life… And I mean that seriously. Far different pace of life (I grew up in So. Jersey and went to school in Philly so I feel I have a sense of your day-to-day), fresh air, no rush hours, a patient population that has a healthy life style and adheres to ounces of prevention… In that regard they are not unlike the Mormons where smoking and drinking is never part of the social history – and so fun to ask about in the history taking because it is any easy joke that everyone enjoys… And, you would need a gun, though you would likely be well-defended given that you would be a valuable contributor to that community…

There are more than a few lessons to be gleaned from studying this alternative approach to our current health care system…

Member

I agree with most of your points in this and others you have posted. However, I disagree that high deductible plans have not worked to reduce spending. Rand Corporation has found “Medical spending declined among all families enrolled in high-deductible and consumer-directed health plans, relative to similar families in traditional plans, with the reductions among medically vulnerable families generally being similar to that seen among other families, according to researchers.” (link: http://www.rand.org/news/press/2011/04/18.html). It has been the corporate world that drove the change…..and used generous health savings accounts….and employee voluntary enrollment. It worked! The ACAs deductibles are shameless….and there are no health savings accounts….so I am not endorsing the ACA approach. I do think Dr. Palmer’s idea of returning indemnity payments would be a great development that would turbocharge reformwhen combined with high deductible plans linked the health savings accounts……and return power to patients and docs, and take it out of the hands of the central planners and bureaucrats.

Member
Jul 21, 2016

Excellent point- I erred in not being more nuanced. I object to high deductible plans with no attention to the unit cost of healthcare widgets. I am in favor of a model of high deductible plans, IF they are combined with reasonable options that work.. In this case, I’m thinking about direct primary care. DPC physicians routinely, for instance, are able to offer basic labwork at sig. lower prices.

Having a high deductible plan, and then having to pay $600 for a chem7 at a hospital outpatient lab…is not a solution.

Member

Agreed. Our employees who decided on the high deductible plan with a company contribution to their HSA became very attentive to costs of procedures and active questioners of their docs when tests were ordered……and that is likely what accounted for the Rand Corporation nationwide study results that showed these plans accounted for a significant reduction in health care costs and slowed health inflation….without a degradation in health status.

And this all goes well with direct primary care…..where docs offer these arrangements and patients are free to sign up and use their HSA funds to pay.

What amazes me is we have a system that reduces costs without hurting health status by restoring power and choice to patients and docs….with well designed studies by well respected organizations (Rand) confirming it……and our health care policy wonks and journalists prefer to forget it in order to keep concocting new solutions which all have the common denominator that patients and front line docs are treated as pawns.

Member
Keith McCallin
Jul 22, 2016

I will study the reference further but, given what you say, there is a presumption that the underlying insurance system is sound. It also accepts rationing health care as an acceptable part of that insurance system.

Distrust of the government I get. We do a lousy job of controlling our government and a great job of whining about it.

What I don’t get is the extent to which individuals distrust government but have no opinion about the resulting default position, that being trust of the health insurance industry. And associated health care industries…

“I hate the government so much I love being unable to afford my medicine.”

Regarding the front line docs treated as pawns. “Economic units,” or like term captures it better. And, with great respect for the many brilliant docs with whom I have worked, I can not feel to sorry for a group of workers who have never in their lives stood to defend themselves or their profession.

And so by inaction, the docs have built the health care system in which they work. And this, to a great extent clarifies the true level of concern they have for the patients they treat and the variable level at which those patients are treated, including not treated.

Member

Here is a link to the Rand summary of their study:
http://www.rand.org/news/press/2011/03/25.html

Note, they did find that those enrolled cut back on preventive care…something that can be addressed in plan design. However, as Nortin Hadler has well documented, much of the suggested preventive care is useless and often harmful.

Member
Allan
Jul 23, 2016

With the exception of vaccinations, I don’t know of any preventative care that need be supplied by the physician’s office at this time. Many consider early diagnosis (mammogram) as preventative care, but as we have learned of late their benefits are not clear cut.

Single payer can only survive based upon rationing for our medical desires can exceed the GDP. High deductible insurance is a very efficient mechanism and preferable (helpful subsidies are always an option). We need patient involvement to keep costs down and to push the system in the right direction.

Member
Jul 20, 2016

Anish- Well written article. Agreed. “Rage rage against the dying of the light.” We need to stop following the rules. As another commented “MDs… have no mechanism that allows for contributing to any change.” That is unacceptable. I believe it will require civil disobedience on the part of independent physicians to bring about change. We must band together and as always I like Dr. Palmers many ideas below … Thank you for the battle call to restore what once was, a physicians and his or her patient.

Member
Jul 20, 2016

Agreed. There are physicians that are spoken to in making policy. It must be that they are n’t speaking to the Dr. Al-Agba’s of the world in formulating policy? The under-represented voice is really the busy clinical physician – and our lack of voice in this debate is a large part of the problem. If the loudest voices are only from the MD-MBA’s who have only dabbled in actually taking care of patients end-to-end, there is little surprise this is where we have ended up.

Member
Jul 21, 2016

I still do not understand why they are not speaking to the Dr. Koka’s and Dr. Al-Agba’s of the world to formulate policies! It does seem like a no-brainer… we are an under-represented voice and I am glad to see we are speaking loud and clear, quite often in fact 🙂 Keep up the good work!

Member
Jul 21, 2016

Because policy can only be made if you’ve gone to a school of public health. Listen to the policy makers on dan diamond’s pulse check – it is remarkable how far these folks are from the actual pulse of physicians/patients.

Member
legacyflyer
Jul 20, 2016

The phenomenon of doctors and nurses being better able to navigate the health care system is not different than other professions/trades.

How good is the legal representation of the son of a judge vs. an ordinary person.
How easy is it to get into the electrical union if your dad is also in it
Etc.

And the other point – that was already made by other commentors – is that the idea that every member of our society has or should have equal access to medical is clearly false.
– Does every kid get to go to the same schools as President Obama’s?
– If the government gives you free transportation, its a bus pass not a Mercedes.
– Free housing ain’t the same as the White House
– etc.

Member
Jul 20, 2016

Very true – but there is nothing the nytimes loves more than the self-flagellating doctor who highlights how broken the system is. And couldn’t agree more about the fools goal of trying to assure everyone has equal access or privilege. Health care, however, apparently falls under the canopy of a mercedes for everyone. We would be better served in health care policy if we left behind the foolish notion that everyone can have everything.

Member
Keith McCallin
Jul 20, 2016

Regarding “…inconvenient truth the control oriented free-lunch-for-all universal healthcare proponents won’t tell you is that cost controls in this system come via rationing…”?

Is not your professional life and Dr. Thakker’s whole article a study in the rationing of care? American-type rationing.

And the “what the…universal health care proponents won’t tell you…”

The most frank, open and in-depth talk about health care comes from those fighting to fix health care. As opposed to the half truths and misinformation coming out of those fighting against any effort to fix health care… Like the wait times. That’s a talking point out of a Whitaker and Baxter inspired public relations campaign.

And if wait times are an anticipated problem to be fixed then there it is, a single payer fincancing system and a privatized delivery system – American style, has not yet been crafted/designed/hammered out yet.

But the bigger issue regarding any opinion from any MD regarding any health care system change is that MDs have no way to communicate concerns and opinions, no mechanism that allows for contributing to any change, or discussion regarding change, to a revamped US health care system.

Remember, MDs were blocked and locked out any involvement with crafting the ACA and nothing has changed.

Difficult not to see that you are between the rock of being well paid and the hard place of being able to give full care to all your patients, and all in the context of a fractured profession that has never stood to promote and defend itself on any level.

And that history of not standing to defend yourselves has put you and your profession right where it is today: At best, well-intendeds constrained under the watchful eye of thieves.

Member
Jul 20, 2016

I would disagree with the idea that we can’t do anything. This discussion would not have been possible 10 years ago. Social media can be a powerful agent for change, good or bad. At the very least – we physicians can vote, the AMA made 260 million in 2014…the tools to effect change are there. We, as physicians, have been lousy at advocating for this. Social media hopefully lowers the barrier. We can also vote.. There is no starker contrast at the moment when it comes to health care.

Member
Allan
Jul 21, 2016

“the AMA made 260 million in 2014”

What does the AMA have to do with physicians in the trenches? One should ask themselves how did the AMA make that money?

Member
Perry
Jul 20, 2016

Here’s another truth:
Happy doctors make happy patients.

Member
Keith McCallin
Jul 20, 2016

With apologies for the continued strong tone: MDs and patients have little to nothing to do with our health care system.

Can anyone seriously argue otherwise?

Which calls to mind the Lown Institute’s good-by-half effort at a quality revolution for medicine. They nail the quality but give no attention to the revolutionary component. Presumably so as not to upset the overseers, I say not facetiously.

Lown needs to hire a couple of bullies for his institute.

Member
Perry
Jul 20, 2016

” MDs and patients have little to nothing to do with our health care system.”

I can’t argue with you there. Which is why I would recommend a Drexit and a Paxit from this system.

See Dr. Palmer’s post below.

Member
William Palmer MD
Jul 19, 2016

Anish, we all feel like this but the train left the station about in the summer of 1982. Sorry. The problem is that there are so many stakeholders now who are eating. We can’t get the system changed until we have funerals.

Member
Jul 20, 2016

Do not go gentle into that good night.. Rage, rage against the dying of the light.

Member
William Palmer MD
Jul 20, 2016

Of course you are right. Your truths put me into a funk. Here is what we docs could do:

1. Work to get indemnity–have all the claim monies go through the patient. He gets the dough and pays the providers.
2. Recalling that slavery is illegal, we could refuse to work unless we are paid in cash or check or visa. Everyone else can do this. We could even insist on payments at the time of service.
3. Recalling that anti-trust does not apply to patients and their agents, we could join with patients and demand a lot of things: interoperability NOW; understandable hospital bills; prices must be posted ex ante; cessation of constant efforts to get us all to die quickly and cheaply; we couls insist that drugs are proven useful before patenting and allowing marketing ( it is already part of granting of patents but is semi-ignored.); closing loopholes in not allowing corporate practice of medicine. Hospitals are hiring docs through their foundations, not directly.
4. Fight to force informed consent to include a default obligation for payers to explain to patients why interventions prescribed by doctors are not covered. It would be illegal not to pay for a prescribed intervention without getting the patients signed informed consent.

Just a few ideas…