That’s a tall order for many American physicians.
Atul Gawande recently addressed the graduating class of the University of Chicago medical school. In his speech, which is an extension of his celebrated New Yorker piece, he looks at so-called “positive deviants,” or doctors who practice higher value, higher quality care, than everyone else.
What makes these doctors so special? In essence, they have to “resist the tendency built into every financial incentive in our system to see patients as a revenue stream.”
Indeed, “These are not the doctors who instruct their secretary to have patients calling with follow-up questions schedule an office visit because insurers don’t pay for phone calls. These are not the doctors who direct patients to their side-business doing Botox injections for cash or to the imaging center that they own. They do not focus, the way business people do, on maximizing their high-margin work and minimizing their low-margin work.”
Unfortunately, most American doctors fail to resist the allure of money. In some cases, it’s greed. But in many others, patients and business have to be intertwined simply to keep the doors open. Doctors cannot practice quality medicine while bankrupt.
Changing physician behavior needs to be accompanied by fundamentally modifying the incentives that influence doctors. Without radical physician payment reform, Dr. Gawande can implore future doctors to fight the financial incentives all he wants, but most will realize that resistance alone will be futile.
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I am loving this thread.
Great post, Kevin, and a very interesting discussion thread. Thanks to everyone for their input.
Patients in this country are frustrated. The problem is, they blame their doctors for their frustration and don’t “look behind the curtain” to see who’s really pulling the strings.
Physicians are the face of medicine but they do not control healthcare. They have also become pawns in the system. Patients get angry and yell at their doctors about the lack of care they receive. Then government and the insurance industry heap more regulations on doctors and cut their reimbursements even more so doctors adjust by pushing more patients through their clinics in cattle cars and running around like hamsters on speed.
When patients (ie- voters) complain about the terrible healthcare they are receiving and yell more loudly about their doctors’ insensitivity, the government and insurance industry smile and explain that this is why we need to give them more of the power over healthcare– because doctors keep screwing it up.
In the minds of most patients, healthcare = doctors. The problem is that this equation was erased long ago. The new equation is healthcare= government/insurance. Don’t worry, though… according to recent proclamations, we’ll be getting a lot more “healthcare” very soon.
Re: “In the minds of most patients, health care = doctors”
Maybe so, but that changes quickly once you encounter a problem. Pretty soon you begin to understand the absurdly complex network of administrators, risk management attorneys, financial advisors, stockholders, malpractice insurers, etc. that all influence and sometimes even direct the doctors’ behavior and decision-making processes.
The “healthcare = government/insurance” equation is also far too simple. Unless you address the incredible bureaucracy and waste inside your own walls, nothing is going to change.
this is a very educational and entertaining thread!
Loved the earlier comment about docs sitting around the campfire singing Kumbyah, untroubled by such demeaning, undoctorly things like making your practice financially viable.
It’s nice to live in an alternative Hegelian universe of pure Spiirit where physicians adhere to some transcendental ideal of charity and selflessness…. but the majority of American doctors actually have to pay bills every month. It’s awful easy to condemn others from your ivory tower academic Harvard soapbox when your referral pattern is guaranteed, you don’t pay malpractice, and your income is entrenched for perpetuity. Spare me the condescension. Most of us have to struggle.
If you want to call for a renewed commitment to “physician ideals” that’s fine. But you need to alter the landscape to make it possible for average community docs to meet those ideals. Articles like the McAllen piece and the commencement address do nothing but supply policy wonks with ammunition to support the proposition that our healthcare woes are entirely physician centered….
Excellent thread.
I’m a physician, in practice. Running a medical practice is running a small business, but a business unlike any other. You form close relationships with your patients, you are often responsible for life and death issues, you need to support your staff also affected by your patients’ personal and sometimes dire circumstances, and then you have to bill for it, make enough money to pay for your rent, insurance, staff salaries (with the occasional raises), and bring home enough to support your family and other responsibilities. I know many physicians, obviously, and I know the vast vast majority of them care way more about their patients and their patients’ health results than they do about their own incomes. Mostly we just want to make enough to survive another day to take care of our patients. Most doctors aren’t greedy, I’m sure of that. We don’t get much business training, learning about business “on the job” and often feeling angry and used when our insurance contracted payments decrease year to year while our rent and staff salaries go up.
Somewhere in all this discussion there’s a “fair” payment for the work physicians do (and their investment in time and money that got them to be the skilled caring physicians they are), and that the patient receives. Maybe the free market can determine that. I doubt that the government or any Insurance company (with executives and shareholders to satisfy) can determine that price artificially. In the meantime I think the moral and ethical course is for physicians to learn about business and try to be as efficient and logical as they can be in their patient care treatments and recommendations. Over the longer term though, the system has to change so that new physicians don’t emerge from medical school with huge debt, and tort reform makes the legal system fairer to everyone (ie docs too).
“Who knows what you do to earn a living, or why you justify being paid to to it.”
I teach remedial mathematics to nursing students. Sometimes I teach higher level mathematics to future doctors. Clearly, investing my time in teaching our future healthcare providers is not worth anything.
“But I promise you, friend, you are being manipulated into anger against the one profession in capitalist society that does indeed care.”
After 4 misdiagnosis (I guess reading my chart is not offered at a McDonald’s practice), I have given up. It’s amazing how quickly you are dismissed when your case isn’t straight forward. To receive effective medical care, a doctor would have to spend more that 10 minutes and I have not found a doctor willing to do that. Doctors are quite content with the status quo and I get my medication with a quick visit once a year-just a few minutes to tell her I fine and I want my drugs. Any real information I get from the internet. When problems come up, I once again get McDonalds care by seeing a PA. It’s about money…I see the PA so my doctor can make more money, I only have 10 minutes so my doctor can make more money. I use the internet because I need help and it is not available from my doctor-not because I want to save money.
“You don’t know of the hundreds of thousands of dollars of free care I have provided and written off.”
It’s about money, isn’t it. It’s interesting you didn’t make claims on how many hours you put it. After 13 years, I am still paying of my student loans.
“BUT I know that any patient with your attitude and expectations can not be cared for to your satisfaction for ANY amount of money.” vs “You are probably treated like a McDonalds customer because…you will get the “dollar menu” care and the doc is going to ask you if you want to “SuperSize” it. ”
So I have received the best care but I am too demanding or I have received the McDonald’s care. Which one is it?
Solutions for Healthcare:
Surely, as a teacher, and mathematician, you can see that “the money” isn’t gushing into your human medical service provider’s pocket…that there is overhead, and liability cost, and that ten minutes in your presence is only part of the time spent on any patient’s case? And that your anger would be more productive if focused on those profiteering from the system who have true malice and selfishness in their hearts?
You must have had some failures as students: no matter what you tried as a teacher, using all your training and all available reference material they just didn’t get it..well, not all human bodies’ discomforts or diseases can be diagnosed or treated to client satisfaction.
I am so sorry if you feel pain, and especially sorry of you feel abandoned. Human to human, I believe no one gets abandoned. Systems are allowed to abandon individuals in the pursuit of highest good for the most members. It sounds like you are ‘in the system’, and doing a good job of trying to help yourself as one of the system’s outliers.
You are either paid by the system(including health ‘insurance’ and pension benefits) or are a sole proprietor tutor. If you receive benefits and guaranteed pay, please use logic, to allow that medical providers have a very different business model than a salaried employee. If sole prop., please factor in the enormous, unique-to-medical-profession, liability risks/expenses borne by these medical providers.
As a fellow human, I sincerely wish you good luck with your health.
Mayo Clinic is often cited as an example of practicing good medicine. However, no one ever points out that their physicians get paid 150% more by health insurance companies than the average, as the insurance companies want to be able to list the Mayo Clinic in their health care provider book in order to look good to its members. Imagine getting paid equivalent to overtime pay just for working full time. So of course Dr. Gawande can hold Mayo’s physicians up on a pedestal stating that they work for salary rather than other monetary incentives and that they are doing fine work. Oh, I’m sure the Mayo Clinic may give excellent health care, but they are given better financial resources to do so than most physicians, especially primary care doctors, who are supposed to be the backbone of medical care and make the least income. (And as a primary care physician, I do believe in spending more time with patients, on the average 20-30 min., often more for more complex Medicare patients. I’ve been doing so for the last year, which has been costly and a struggle financially. Yet I have come to appreciate that you don’t need to make more than a modest living to be happy. I also don’t consider myself a slacker. I try to be thorough. I’m still averaging at least 2-3 hours after work doing after hours paperwork, callbacks, etc.) Well, most primary care doctors mostly practice in small groups or are solo practitioners and thus have very little negotiating power when it comes to compensation from health insurance companies. A lot of the public don’t realize that the insurance companies have different compensation rates even between health care providers from an identical specialty in the same community. Honestly, I am skeptical of physicians giving mandates from the ivory tower.
This is a great topic!
In my line of business I have this conversation to a certain extent every day with Dr.’s. No kidding, every time I step into an appointment its always the same response when asked ” what would you change in your billing if you could?”. I always get the same answer 99% of the time ” I would like to get more money out of my billing!”. This is nothing new to me and I have to admit at first I was skeptical of the Dr.’s ethics when hearing this answer but after further research and many conversations covering the same results, I know why Dr.s reply with this answer. Not to any surprise to many of you but many insurance companies dictate what they will pay and what they will not pay even though you code the bill to specific approved codes. That doesn’t seem fair and so the questionalble debate arises with the scenario of Dr.’s giving the “on the side Botox injection”. Maybe if the insurance companies would pay for what the coded procedure promises this would never be the case but in reality its not. Not to mention that Dr.’s simple do not get paid what they used to.
So within you will hear my solution to this small part of the problem. And in saying that I am going to start out with my frustrations of this repetitive topic.
In my line of business you get the infamous gate keeper! Here are the types that will hurt/kill a business (and I talk to these guardians more often than not!): 1) the person answering the phone and does not pass the message on or stops you immediately from getting past them, 2) the person (often practice manager) that fields the appointment but neither has the authority to make a decision nor has the knowledge of what the Dr’s. needs really are, 3) the Dr. (yes I said Dr.) that has been with the same system for years and either simply will not change OR they do not know what the compitition has to offer, in other words do not know what else is out there and my personal favorite 4) (sigh) the billing person (manager) that is afraid that I would take their job regardless of the fact that what I have will save the Dr.’s business thousands and thousands of dollars each year. Honestly, I don’t see the last that often but nevertheless, I do run into it occasionally and I say its my favorite in passing becuase this selfish, egotistical act is the primary reason why it is costing the Dr.’s business money rather than gaining money…..the literal contradiction of having a billing person on staff- to insure money coming in (wheres your ROI on that?). Any of these combinations will yeild less money than gain in any business.
By using new technology and streamlining processes, primary care practices can reduce their costs to half of what a typical practice pays, from about 60% of income down to 30%. To quote TampaDoc ” am sixty years old, working non stop with a 70% overhead. Employing personnel to satisfy insurance mandates…. somone to verify insurance, someone to do pharmacy overrides, someone to fill out forms, someone to get approval for radiologic studies, etc…” So not all of you are 60 years old but this is a very common and realistic scenario in owning your own practice.
Again, this is only a solution to a small part of the puzzle . I met with one practice and saved them $36,000 a year, another practice I saved them $28,000 a year and they actually had used the same system for over 15 years……do the math with that one! Also they were looking at a 35+ day return on their bills! How does that work? Now add in their 40% of rejections and to top it off think about the time frame on their past due accounts.
So in consideration of the topic (and I hear this every day at work because the money aspect of medical practices is my line of business), this should be a self evaluated question on what Buckeye Surgeon poetically put it ” the proposition that our healthcare woes are entirely physician centered….”. Of course money matters and being able to retrieve your money is not a greedy ingredient!
So my solution is to start in house and look at your A/R’s. What can you change there and what is out there to best assist you in your analysis? I didn’t post to start an advertisement but come on Dr.’s…..the same repetitve question can be answered and I can give you a side by comparison of what your current billing system is compared to mine. Please contact me @ aperez@fortsonservices.com . Whats there to lose? Maybe if more Dr.’s were getting paid what they are supposed to get paid from the insurance companies this wouldn’t be an issue.
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