How the health care system is corrupting doctors

Originally published in HCPLive.com

by Jeff Brown, MD

I had the same reaction . . . shock at seeing an almost obscene claim about our profession in a national newspaper. But it got me thinking, which no doubt was its intended purpose. While we are thinking and feeling our way through this wide-ranging debate on health care, we might as well examine everything. And as we have painfully learned, no part of life is immune from money issues, especially medicine.

Corruption, for our purposes here, is the bending or abrogating of our integrity, putting forth what is “best” for our patient as a result of venal or other outside influences. We may not think about it much but we are assaulted on a daily basis in many ways, some obvious, some subtle.

The poster child for lobbying physicians is the drug rep. Before Congress began reining in Big Pharma’s largesse over the last 20 years, there was a time of thinly veiled bribes—trips, cash for “consulting,” speaking and research—and my office was once booked over a month in advance for catered lunches for the staff. “Any restaurant you want and anything on the menu,” we were told. We thought it was just a nice perk for the staff and kept them around the office.

And don’t forget the endless supply of company-name-stamped tchotchkes, of course, or the embarrassing feeding frenzy at national medical meetings where presumably ethical and well-paid docs and their wives rushed to fill bulging goody bags with “free” junk in the extensive exhibitor’s hall.

We should ruefully admit that these companies weren’t blindly spending billions on these programs and couldn’t document that these things worked. In spite of our righteous protestations, they did. Did you know that drug companies still pay a monthly fee to pharmacies to see a specific read-out on what and how much each doc prescribes? They know that we too are human and our prescribing habits change, admit it or not, when the companies pay personal attention to us.

Good riddance to the drug companies’ more flagrant gifts: it’s been a long time coming.

Now let’s revisit the biggest corrupter of all, the fee-for-service structure. With all the economic pressure of student loans, high overhead, family needs and on and on, it takes a steel will to stay on point. Not to yield in those extensive gray areas of decision-making and perform extra procedures, schedule extra visits, order tests through facilities in which we have an economic interest, or change our prescribing habits all require a major effort to keep ones eyes on the horizon. And worse, in addition to our personal rationalizations, our patients often demand that we do these things! So we acquiesce, knowing that we are often just buying time for problems that will get better anyway . . . and really, what’s the harm?

Ironically, the knock we’ve had against HMOs/managed care—that being paid for doing too little is a bad idea for our patients—also applies for fee-for-service which pays us too-often for doing too much. That’s why I have written in the past that putting docs on salary would mitigate the cost of health care considerably. Yes, there are other issues that arise with docs on salary, like maintaining activity and quality levels, but that discussion is for another day.

Corruption is also engendered by the insurance companies being inefficient and just plain difficult. It is axiomatic that when you are dealing with a dysfunctional system, the only way you can get your work done is to game the system. So you or your staff manipulate things like CPT, ICD-9s, and other forms without end. You say it’s only “fair” and that you are just trying to help your patient get what they need by doing whatever it takes. This is too often true and we’ve all done it. But it is not “clean” and diminishes us each time we do it. The ends certainly do not justify the means.

Even putting ethics aside, all of this costs time, which in our trade is money. Because time is all we have, besides our good names, we are corrupted and bent away from our primary mission. I’m reminded of the old saw that says, “We all know what we are, we’re just dickering about the price.”

But I’d like to think that our profession still aspires to set a standard for others to be better than that.

Jeff Brown is a family physician who blogs at Take As Needed.

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