When the business of medicine trumps appropriate care

I almost fell off my chair.  It was bad enough that he showed up to the ER.  But what happened next really blew my mind.  He fell and bruised a rib.  The pain in his left chest had obvious enough origins.  But triage had put in for an electrocardiogram and the interpretation apparently scared the resident.  The attending took a look, and shook his head.

“Left bundle branch block.  Better call the Mecca.”

A few minutes later a cardiologist and nurse manager were videoconferencing in and interviewing the patient.  Next came an order for thrombolytics and transfer to the big medical center ninety minutes away by ambulance (the same medical center that owned the emergency department as well as the local hospital the ambulance bypassed).

Rules are rules.  And the bylaws state that all patients given thrombolytics have to be transferred to the brand new multi-billion dollar cardiovascular institute no matter how far a distance.  It didn’t hurt that said institute was having trouble filling it’s beds and apparently the administrative folks were starting to lean on the clinical staff.

The cardiac cath was mostly clean.  Was it an overcall, or did the medicine really just do a great job? He was never given a clear answer.  He left the hospital with more questions then answers, and a prescription for a baby aspirin and a statin. He came to my office to try to figure out what had just happened to him.

This sort of thing seems to be occurring more and more often.  The business aspects of medicine are starting to trump appropriate care.  While no one is saying that more is better, aggressive management has become the rule and not the exception.

Healthcare reformers, politicians, and policy wonks wag their fingers at physicians and place the blame squarely on our shoulders.  They say that only the doctor has the power of the pen.  They completely ignore the bullying, administrative pressure, and the automatic rules and regulations forced on clinicians by the nonclinical (or no longer clinical) c-suite.

A recent article in American Medical News brings to light a radically different view point:

When the federal government sorted through the first round of clinical information it was using to reward hospitals for providing higher-quality care in December 2012, the No. 1 hospital on the list was physician-owned Treasure Valley Hospital in Boise, Idaho. Nine of the top 10 performing hospitals were physician-owned, as were 48 of the top 100.

This news comes three years after the Affordable Care Act effectively prohibited the expansion of such existing facilities and severely limited the creation of new ones.

As Obamacare pushes more and more physicians out of decision making positions and herds them into large academic and nonacademic hospital systems, one would expect one thing and one thing only: spiraling costs.  Business exists in order to make money.  Businessman go to school to learn about profit.  Physicians who leave clinical practice to become administrators aspire to similar ends.

Physicians are the only ones who have made a covenant.  We are the only ones who have taken an oath.  We are smart, well educated, and innovative.  And we have to look each and every patient in the eye before making decisions.

Yet time and time again, we are asked to move out of the way so the smart guys with the business degrees can come in, and make the tough decisions.

(This story is an amalgam of a number of experiences gleaned over years of practice in a number of different hospital systems.  The details of the actual medical story are fiction.  Neither the patient mentioned or the medical center are meant to be reflective of any specific patient or hospital.)

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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  • http://www.facebook.com/johnckeymd John Key

    Physicians ARE to blame–but not for the usually-stated reasons of avarice, greed and pride. Rather they are to blame for willingly ceding control of the health care field to non-physicians.

    This shift in responsibility and authority has not been forced upon us, it has been willingly given over the last four to five decades.

    Physician control could be re-asserted, but I fear that there will always be a lack of critical mass of doctors with the stout hearts and wherewithal for the task. Even now such figures who do arise are derided as “cowboys” who lack sufficient sensitivity to bend to the alleged wisdom of the “team approach”.

    The future is not bright.

    • azmd

      The case above is really not a very good example of what you are talking about, involving as it does CMS-imposed quality indicators and their mindless application.

      Would you suggest that hospitals stop accepting Medicare? The medical profession really had no opportunity to control which bureaucrats were put in charge of Medicare, so the only other option would be to opt out of third-party payment. For docs in private practice, that’s feasible, and more of us should be doing it. But for hospitals, especially teaching hospitals, it’s not a choice.

      • Ed

        You’re right, any doctor or hospital who accepts the government’s dime has to dance to the government’s tune.

        • karen3

          And the government’s tune is that suffocating a patient for 15 minutes — no problem. Stage IV pressure ulcers, no problem, causing paraplegia due to personell walking off of the job, no problem. No infectious disease control process + superbug — no problem. Piss ant coding issue– Armageddon.

          • Maura69

            Almost a year ago I had a CTR (Carpal Tunnel Release) and prior to surgery they issued a mandatory MRSA test. I went to my local hospital to have the test administered and they were unable to comply, consequently I had the test at the hospital where the surgery was to take place. The test was fine and the surgery was fine. Two weeks ago I had a pre-op for another procedure at my local hospital and was pleased to find out they are now testing for MRSA. CATCH: they will only administer the MRSA if you had been positive for MRSA previously. Unknown to me, the “catch” I answered, I am so happy that you are now administering the MRSA test for surgery patients so that you, (staff) and I are protected. Big surprise – they will only administer if you have been positive in the past. I ended up having an excellent pre-op nurse and she proceeded with the test. I am fine and recuperating but I do not understand why this local hospital will not automatically administer the test. It is beneficial to all concerned!

  • icecoldchickenwings

    While I don’t dispute the underlying economic motivation that the author of this article implies, I will aslo point out that it is a culmination of “the business of medicine” as well as the cya of over testing compounded with the continued algorithm cookie cutter recipe of medicine and the government supervision of “quality measurements” of hospitals.
    I realize this is a fictitious patient however, time of presentation of the ED with chest pain to an EKG and aspirin therapy +/- thrombolytics is a quality goal measurement of the federal government. The fact that guy with chest pain from a bruised rib probably doesn’t need an EKG in the first place (the circumstances of the fall are not provided by the author) is irrelevant in 2013 beancounting medicine as it currently stands.

    Chief complaint fall and chest pain in the ER = grading by the government = immediate EKG = “therapy”. While I agree this is flawed logic I don’t entirely fault the cardiologist on the other end as he sees new bundlebranch block? and he uses the tool he is familiar with to evaluate the problem he knows how to deal with (he/she is not interested in the bruised rib and could be potentially be sued if this EKG change were to represent any problem and he dismissed it because of a bruised rib).

    Costs will spiral, and administator types are in part at fault however, the requirement for an EKG for all chest pain, including obvious non-cardiac origins, is going to escalate costs far beyond just obtaining EKG’s and this requirement can be squarely placed on the government grading of hospitals. Try, just try, to argue against this at a med staff meeting (some of our local cardiologists have to no avail) as we were told that CMS is grading time from presentation to the ER with chest pain to time of EKG and therapy is a quality of the measurement of the government and there is nothing that can be done about it if we want to have good “quality” scores. Welcome to the new world order.

  • http://twitter.com/ppalmierimd Peter Palmieri

    If physicians are being pushed out from making key medical decisions, it is partly our fault. Medicine has become increasingly impersonal as physicians have gravitated to technology and abandoned the much more personal approach of collecting a good history and physical exam. Some of us have gone to 9 to 5 hours, relying on answering services, after-hours clinics and ERs to rescue our patients in their times of need.

    In short, we have placed a distance between the patient and ourselves, and as this has happened, other parties filled the chasm. If we want to make decisions on our patients, first we have to be there.

    • icecoldchickenwings

      I agree with this statement although I do feel the government is complicit in part of this effect. A lot of primary care docs feel they can’t stay in business seeing inpatient Medicare because the reimbursement is so low and as such we have hospitalists.

      Hospitalists beget outpatient primary care for the hospital and its not much of a leap. A rural multi-specialty group I used to work for got the squeeze. First it was couldn’t go to nursing homes because of low pay, then it was leave it to the hospitalists because of the pay, then it was no weekend hours because there weren’t enough docs to cover.

      This is only gonna get worse as the next generation o docs is more interested in a comfortable lifestyle than a calling. For the first time ever more new docs start by working for a hospital pr a large group. That multi-specialty group eventually got bought by the hospital (facility fees will make it profitable). I suppose that’s what happens when pay stagnates and the government gets involved.

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

        What’s mind boggling to me is that we (i.e. Medicare) say that we don’t have enough money to pay community primary care to do things right, then we turn around and pay more money to other “players” to do it wrong, then we whine that doing things wrong is more expensive, and finally we plan to spend even more money to make it even worse because this is going to save us money…..
        Is there an entry in the new DSM for this disorder?

        • icecoldchickenwings

          It’s called crony captilalism and the end result is always the same. Innovation, efficiency, and indepdence are all stiffled while laws are used to protect the big guys. Same thing with banks and too big to fail. In medicine Its not all about fees. The hospital I used to work for (between private practice jobs) had an ENTIRE department to make sure the docs met meaningful use. Small private practices lack the resources to keep up (another reason they sell themselves to the big guy). For meaingful use EMR vendors are the ones in bed with the government, but the end result is the same.

      • http://www.facebook.com/profile.php?id=100003228017539 John Mitchell

        “That multi-specialty group eventually got bought by the hospital (facility fees will make it profitable).”

        Dr, Ramoray, this is a widely held misconception among physicians and some hospital administrators, as well. A good way for a hospital to lose money is to purchase a large practice and employ the physicians WITHOUT productivity as part of their contract. And my experience is that physicians who have been used to running their own practice bristle under the requirements of having part of their compensation based on how much they work.

        When I was at HCA in the mid-90′s I was peripherally involved with a year-long negotiation with a large, multi-site primary care group to purchase the practice and employ the docs. We always had to meet at 7 a.m. or 7 p.m. when the practice was closed. The day the deal was finally inked, the division COO asked for a meeting with the lead doctor to finalize some transition details. The COO asked if the doctor wanted to meet early or late, to which he replied “Oh, lunch time will be all right.” It wasn’t his money any more! Within two years, productivity and profitability had got so bad that HCA spun the practice back out to the doctors. Its human nature.

        I agree that new doctors are more focused on a balanced life. Some will even trade more time off for less pay. But the doctor who has been around for a while often wants to eliminate the risk of owning a practice but be employed by a hospital for the same compensation. Its not sustainable over the long run and something is going to have to give. Because hospitals will go broke trying to employ doctors under old compensation models.

        • Dr. Drake Ramoray

          I was not suggesting a salary model would not decrease productivity. It is a widely held and accurate belief that that does decrease productivity I was pointing out the additional facility fees for the exact same service will help profitability. One of the only differences is the sign on the building.

  • http://www.facebook.com/andreaschaerf Andrea Schaerf

    Medicine as business, dulls the intellect. Linear thing and lack of creativity get rewarded.

  • http://www.facebook.com/profile.php?id=100003228017539 John Mitchell

    As a hospital administrator I would never tell a physician how to practice medicine. I always left protocols to the Chief Medical Officer and Medical Department Directors. It was my job to make sure the resources they needed to take care of patients was available – to make my hospital a good place for doctors to practice medicine. During my career I also saw instances where physicians made decisions and took actions to maximize their billings and income ahead of was best for the patient. This includes delaying a referral to hospice so that a physician could bill for a few more days of inpatient rounds. There are good and bad administrators and doctors.

  • Dorothygreen

    We “as a nation” need to stop using bandaids to correct our very sick health care problem. There needs to be real change – dramatic change. We need a health care system in the US and we cannot have a private market driven care for essential services. Physicians, hosptials, government, equipment and pharmaceutical companies and insurance companies all need to sit at the negotiating table and set prices and rates for essential services for everyone. The competition and profits comes with supplemental insurance when folks want choice of physicians, a private room, other perks, fancy equipment, unproven procedures. Alternative care

    There is one model in the world that is like this. It is Switzerland. Occasionally there is a story about this on TV, serveral economists see the fit.
    If we don’t get the bigs out of essential health and we don’t Creatively Destruct our Standard America Diet as well as get the BIGS out of essential services we will not solve our deficit reform our eating culture which drivers the over spe the BIGS the

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