This is the greatest flaw in medical training

Perhaps the greatest flaw in medical training is our blatant avoidance of any education related to the business of medicine. Primarily focused on treating illness, trainees often don’t want to hear about how they are going to be compensated in the future, and medical school administrators fear that such training would further decrease interest in specialties that reimburse at a lower rate per unit time. Some doctors get 10s and 20s out of the health care ATM every day while others, unfortunately, get 1s and 5s. As a result of ignorance, too many new doctors wind up facing a steep learning curve or risk being taken advantage of while locked into a non-compete agreement at their first job.

I received an education of my own while participating in a moonlighting opportunity at a for-profit imaging facility late in my residency. While most doctors work far away from the point where patients check in and pay, I was in close proximity to this area at the facility.

The first factoid that became apparent is that almost nobody really understands what his or her own health insurance covers, and many are shocked when they realize that they may have to pay out of pocket a sum that could be hundreds of dollars. Actually having insurance, though, may be a bad thing at the particular facility I was at, because it would mean that a scan could cost $2,000 or $3,000 with the patient responsibility for a copayment or deductible sum representing a large portion of that. In contrast, I learned that uninsured patients may only be charged $300 to $600 cash, and the intake personnel were not allowed to tell them that.

What’s worse is that while a significant portion of the clientele had poor health benefits that covered their posteriors about as well as a hospital gown, many (if not most) of the patients were paying a lot out of pocket for scans that were either ordered incorrectly or completely unnecessary. In other words, had their doctors called me first or used the publicly-available criteria created by the American College of Radiology, significant expense would be eliminated.

Next is the actual facility itself which was not doctor-owned but what I refer to as “entrepreneurial,” meaning that a group of investors got together to buy scanners for the sole purpose of making money. While this may seem like a means to avoid the sort of self-referrals that make doctors seem greedy, it can be a bad thing because there is no law that prevents a facility from generating high charges based on suboptimal images acquired from scanners built ten years ago. What’s more, the facility can rack up additional funds by requiring and performing kidney function tests even when they aren’t necessary. In contrast, every VA that I have spent time at required equipment upgrades every seven years. This is not an instance where the for-profit sector benefits patients.

Caught in the system are the doctors, many of whom opt to be employees of larger institutions and engage in such relationships without knowing what is really going on. As a radiologist, I would be justified in commenting on inappropriate orders or images in my report, but I am disincentivized to do so because it places the whole study at risk for not being reimbursed.

Most of my work now is in the hospital setting where payments are structured differently than in outpatient scenarios, but I look back on this brief experience as a lesson in treatment of the whole patient, not just his or her scan or illness. I urge medical students to spend half a day at the front counter of a clinic or even in the waiting room. You get plenty of training in settings where death and illness happens. It’s important to see where life happens too.

Cory Michael is a radiologist.

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