Business principles are applied to American medicine to an extent found in no other country in the world.
Every procedure, office visit, or hospitalization is assigned a quantitative work value, known as relative value units, that is used to base revenue and salary decisions on.
Harvard physicians Pamela Hartzband and Jerome Groopman looks at how such a fiscal-based system affects medical decision making. The results are predictable.
In general when money is a factor, it “promotes behavior marked by selfishness and lack of collegiality.” In medicine, this leads to doctors becoming “so alienated and angered by the relentless pricing of their day that they wind up having no desire to do more than the minimum required for the financial bottom line.”
Activities that are not reimbursed, such as spending time talking to patients and coordinating care with specialists, are discouraged, since no metric exists that measures “the quality that derives from the communal dimension of medicine.”
As regular readers of this blog know, the business aspect of medicine influences the choices of medical students. “Today’s medical students are being inducted into a culture in which their profession is seen increasingly in financial terms,” the authors write, adding that with the addition of “such pressures as the need to pay off enormous debts, and it is not surprising that students’ choices are dictated by the desire to maximize income and minimize work time.”
What’s the answer? One suggestion is to adopt the patient centered medical home. This concept redirects financial resources to pay for services that are not currently valued, including spending time with patients, managing chronic diseases, and reimbursing for telephone time and other forms of patient communication.
It’s been shown time and again that money influences physician behavior. Changing it to improve the physician-patient experience will require a fundamental reform of how doctors are paid.
Related posts:
- The business of medicine
- Business and medicine
- Medicine is a business . . .
- Practice medicine like a business
- More on the business of medicine
- Op-ed: Doctors are forced into running a business
- There is no business like medicine
{ 6 comments }
You’ve set up a false argument because you’re confusing business with bureaucracy. All of this baloney you cite are attempts by government and third party payer bureaucracies to limit care and care payment.
The small parts of medicine that have free markets such as cash practices and uncovered elective procedures are largely free of these hassles.
Great post. The consequences of making medicine a business is reminiscent of recent posts including the kidney drama as well as Pauline Chen’s lastest article about the challenges of putting a price on compassion. Together, they raise a central question about our medical and healthcare system. And as mentioned, influences how physicians and other medical practitioners make decisions as well as the role patients play in her or his own care. But making medicine a business carries much greater weight about what “counts” or what gets “reimbursed” as you stated and framing medicine as a business demands a certain kind of communication and decision making process as well as influences the culture medical students are being educated and trained for. And if medicine is framed as a business, we must, together, enhance the inclusion of wider social values and underrepresented groups and interests into medical practices and decisions. Furthermore, what’s getting counted for at the expense of something else like compassion, collaboration, and community must become part and parcel of today’s medical students training and culture. Moreover, this responsibility should not simply fall on medical students and doctors but also the responsibility of patients who become active agents in their own care. Doctors need our help and we need their guidance to rearrange the extent to which money is enmeshed with medicine and how medical decisions are made and how they could be made differently. This agenda is not about what doctors or patients want but about a conversation that isn’t taking place. This conversation must happen in order for all providers and patients to decide how medicine gets done and what should “count.” After all, business can be a productive word if (and only) the communication is transformed. Thanks for the insightful post….
Die Kunst geht nach die Geld. The art follows the money.
Although those of us trying to do primary care feel this acutely, you can also see this being played out to its logical conclusion in specialty care as well. A FP colleague from Arizona was telling me that is is next to impossible to find a dermatologist willing to take on any medical cases such as tough to treat eczema, etc. They only want to do cosmetic work. Seeing patients that need education and medication treatment just doesn’t pencil out.
Since I started my own "cash practice" nearly 2 years ago, there are only 2 times I order expensine unecessary tests, or send soft referrals to specialists – either when it's really medically indicated based on evidence of benefit – or when I practice defensive medicine.
My cash paying patients pay for my time, plain and simple. There is no need for me to do holters, echos, ultrasounds, ekgs, spiro's, screening hearing tests, ABIs, x-rays, nerve conduction studies, and bladder scans or anything else in ordere to generate $120+ per encounter. There are very few indications of biopsies, or joint injections. My $1500 per patient fees removes all incentive (both concious and unconcious) for me to add wastefull ancillaries. Toss in the fact that my patients can pay for the membership out of HSAs, we are saving the system money, my patients time, and improving the quality of care. I recently ran a quality reports run show how good of a job I'm doing. Colonoscopy, mamogram, pap smear, flu and pneumovax rate are greater than 90%. Zostervax for 60 and older is 75%. Average diabetic a1c is still a little high though at 7.3 and 73% of my hypertensions qualify as controlled. BP<140/90 on 2 successive visits. Aspirin use is at 85% for males older than 65. 85% of my a fib patients are on coumadin and the 15% not are clearly documented why not. Therapeutic Vitamin D levels in 100% of my patients.
The cash model works, plain and simple. Here, the money follows the art of medicine.
*quality numbers are currently based on a small sample size
Concierge Doc:
I offered the German proverb above–and sort of agree with you but the proverb still applies. In your cash price system, patients are offering their money to hire a physician–and a physician is what they get. They value you for your professionalism (skills and ethics) and don’t see you as just a faceless utility that they have to go through “to get a test” and have it paid for by insurance.
So the Art is following the money because you structured your practice so that the the payment structure will reinforce rather than conflict with the art of traditional Hippocratic medicine–which is the ethical way of mixing business and medicine. Good for you.
Comments on this entry are closed.