Fewer choices for patients with health care consolidation

As a specialist, one of the saddest truisms about practicing medicine in the private world has always been how little one’s clinical skills determines referrals. Unfortunately, as our present healthcare climate pushes “providers” to consolidate along the lines of major hospital networks this injustice will only worsen.

A decade-or-so ago when I started private practice it was obvious that referrals came to me because of my association with an established group. This association was essential, as one could have been the next Michael Jordan of electrophysiology, but referrals would still have gone along historic lines, to the favored group. It would have taken a herculean effort, over years, to encroach upon such long established referral patterns–etched over the bonds of rituals like Wednesday afternoon golf matches and dinner clubs.

Thus, few specialists start independently. You join an established group, do good work, form relationships and eventually, your quality becomes known. As it should be: do good work and doctors will trust you with their patients. But yet, even the highest caliber specialists may fall prey to the easily accessible, affable, but (unknown and untested) new guy.  For enhancing referrals, availability and affability trumps skills—at least ninety percent of the time.

Now there is a new trump card for referrals: physician consolidation. Who owns who. For example, hospital X’s primary care doctors refer their cardiology (substitute any specialty) to hospital X’s cardiologist.  And so on with hospital Y and Z.  Like in this example, as one local oncologist bemoaned to me recently: “referring doctor Y used to refer me all his patients, but since the acquisition, he sends his mom and brother to me, but sends the rest of his patients to his new mother-ship’s oncologist.”

My message here is not to cry sour grapes, but rather to echo two themes.  First, to mirror the message of the WSJ’s recent editorial—although a goal of healthcare reform is to enhance competition, paradoxically, in the case of incentivizing provider consolidation, patients’ choices are diminished. You (the patient) will be seeing our cardiologist, or our surgeon, or you will be having your MRI at our (smaller, but less costly) scanner.

The other motive for highlighting these new allegiances is that patients should understand the mechanisms at hand in deciding which specialists they are recommended.  Isn’t it fair that a patient know that their doctor may have signed a contract agreeing to use the ‘company’ doctors? (Sure, there was a also a clause in that same contract saying the ‘company’ would not interfere with medical judgement, but we all know that persistent rogue referrals will likely result in an unpleasant fireside chat.)

In employing doctors, the primary master of the profit-driven health care corporation is physician productivity; CPT codes and work RVUs are the grading system, the language.   The code for an ICD implant is 33249 and its reimbursement is set, regardless of whether it is appropriate, or done right. Hopefully, the companies that employ the best doctors will find ways (besides profit) to distinguish themselves.

Providing higher quality care, to millions more, at lower costs will surely have its consequences. Undoubtedly, for patients one of these will be fewer choices.  When eating for free, only the most daring ask for a special order.

Be daring.

John Mandrola is a cardiologist who blogs at Dr John M.

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  • http://warmsocks.wordpress.com/ WarmSocks

    I have, unfortunately, run into this sad state of affairs. I’d prefer to see the best person out there, not the one who happened to sign on with a specific hospital. Sometimes asking isn’t enough.

    My rheumatologist is affiliated with a hospital. When she wrote a referral for me to see the hospital’s podiatrist, I asked if she’d object if I saw the independent podiatrist that our family physician had referred a different family member to. She had no objection to my seeing him, but said that hospital rules wouldn’t allow her to write a referral for it. That makes me mistrust any future referrals she might want to write. I’ll gladly pay to see my independent family physician so that I can ask him who he thinks is the best in the field, then choose my doctor based on criteria other than which hospital the person is affiliated with.

  • Alice

    I appreciate your forthrightness….I will say it is very difficult to choose a doctor. We can search rating sites…a bit of an emotionally, confusing journey I try to avoid…we can do google searches of our disease…in our case a terrifying journey…you can google the doctor…sigh…either the doctor is a wanna be author willing to compromise for a type of fame (often under the guise of public service)…or the doctor is complaing about management, time constraints, burn out….good people you are terrified of going to for fear of being lost amidst their sea of faces…….more mental confusion.

    Finally, you ask a doctor…he gives you a name..tells you this is who he would use…but you are not a member of the esteemed colleagues club…defeat overcomes you. You ask…how can I speak your language…understand you…why do I feel so frustrated, so overlooked….lost in two seas…one being a patient..one being the high seas of a type of doctorese.

    Then the groundbreaking EMR’s that are helpful…but can include a type of doctor’s private journal about a patient who has no access to these portions about the doctor’s perceptions of you. Changing doctors is not easy in this type of big hospital system where the patient cannot imprint upon their records why they switched and doctors cover for colleagues (because bad patients are the norm on these high seas where doctors ride the waves as a type of perceived pirate:).

    It is a frustrating ride amidst the travails and waves…the journey can be treacherous….but even though we can feel shipwrecked…I am so grateful and starting to think we just may arrive at our destination having learned some invaluable skills worth sharing.

  • http://www.blog.neurokc.com Aaron Seacat, MBA

    No Man Can Serve Two Masters
    John Mayo said, “the only interest to be considered is the best interest of the patient”. As hospitals acquire a majority of the primary care practices – physicians are involved in an ethical delimma – specifically a Dual Agency problem. More on the Dual Agency Problem here http://bit.ly/d6j2Um

  • soloFP

    I have watched the inside referrals for years. The hospital has multiple groups that are supported in town under separate Tax IDs to keep Medicare from becoming suspicious. Magically the primary docs keep their referrals to specialists and testing facilities that are owned by their employers. One employer even has special insurance that will not allow the hospital employed to go outside of the hospital without paying a deductible and higher copay, once the deductible has been met.
    I have noticed that the employed hospitalists magically get a consultation from almost every specialty from their employers on most inpatients. Studies usually show that hospitalists save money to the hospital, but they often cost the patients more money with excessive testing and excessive inpatient consultations. I have noticed that hospitalists order PFTs, Echos, CTs, and labs on patients when the outpatient docs fail to communicate to them that the same tests were just done on the patient. I have seen patients get daily normal CBC, CMPs, chest xrays, with all normal results for 3 or more days in a row. Medicare and the patients end up paying for the tests, as Medicare has no limits on the number of tests that can be ordered on different days. Another employed doc ordered six pfts in 1 year on a patient with Medicare, and another patient had 10 chest CTs in 2 years at the hospital scanner. The more complex the care appears, the higher the DRG and billing levels.

  • family practitioner

    We would not be having this discussion if private primary care practice had not been enduring a slow, painful death over the past 10-20 years.

    I started my practice in 2002, and after years of barely making it, despite around 100 patient visits per week, hospital rounding and 24/7 free access for my patients, I had nothing to show for it but a 130,000 salary. Now at age 45, I give up and am moving my practice to a hospital affiliated group and will be making 187,000 plus productivity, for less work and better benefits..

    Only a fool would not take that deal.

    And specialists who may lose some of my referrals? Crocodile tears.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      I probably shouldn’t ask this, but how does the hospital define productivity? Is it above a certain number of visits, a certain level of charges, or does it include the number of referrals to hospital facilities and employed specialists?

      • family practitioner

        productivity is done ny rvu’s, an imperfect system, but better than number of visits or money brought in. Referrals do not factor into the equation in anyway whatsoever.

      • Leo Holm MD

        Human beings are products. Did you not know this?

    • buzzkillersmith

      Well said.
      What we have in this country is a medical system that is rotten to the core-or the base-the primary care base that is. This results in care that is more and more expensive but still gives poor results. And so now we these maneuvers on the part of payers and the government desperate to control costs, maneuvers which just screw things up more. Meanwhile the rot continues as the sub-specialists have a lock on the RUC.
      This is no way to run a railroad.

  • http://drsamgirgis.com Dr Sam Girgis

    Primary care private practice has become increasingly more difficult to sustain. The salary expectations for primary care need to change, they are ridiculous. If they don’t, everyone will be shifting to employed primary care with fixed salaries and better benefits. As such, the referrals to specialists will go to the physicians who are affiliated with the salaried physicians. I agree with family practitioner above- specialists who may lose referrals… crocodile tears.

  • soloFP

    The big problem with employment and production is that if you don’t meet your quotas, initially you are given a warning. Multiple months of quarters of not meeting your quotas yields a 30-60 day notice that you have been terminated. With the no compete clause, you end up having to leave your patients and start over somewhere else.

    • family practitioner

      Sorry, but that is not how my contract reads.

  • pcp

    I think ACOs will make the ethical problems even worse. The physician practices will not necessarily be owned by the hospital, and, therefore, it seems, patients may not realize that they are being treated by an ACO. The initial ACOs will be only Medicare patients, so physicians may have financial incentives to treat different groups of patients according to different standards. The icing on the cake is the the doc may actually profit by sending an ACO patient to a cheaper but not as good specialist. What a swamp!

  • Leo Holm MD

    Well, so much for the “free market” and “consumer choice”. It’s a good thing all these hospital administrators know what’s best for patients.

  • http://www.blog.neurokc.com Aaron Seacat, MBA

    In my region, one of the big insurers dropped a large hospitals system instead of conceeding to their demands for 47% reimbursement increase over 3 years. This lasted for only a few months before the insurer came crawling back.
    My question is this: If the hospitals have such leverage in setting reimbursement rates – are they intentionally keeping Primary Care reimbursements low so that they can become the saviors of primary care by paying more?
    Hospitals can use primary care as a loss leader – as long as they keep a strangle-hold on the testing and procedures with inflated prices and faciltity fees.
    A rising tide lifts all boats. Using their power to negotiate appropriate reimbursement for hospital owned primary care phyicians would have a negative impact on their overall bottom line if it trickled down and made private practice financially sound. Don’t count on it happening soon.

    • Leo Holm MD

      Primary Care is the 99 cent value menu of the hospitals.

    • gzuckier

      but isn’t the theory that proper primary care will minimize avoidable hospitalizations? suggesting we should be skittish about getting our primary care from hospitals.