Healthcare: The Desirable Duopoly Of Doctor & Patient

Guest post by Daniel Kaufman MD

Ask any corporate tycoon what the toughest business structure to beat is, and surely they'll tell you it's a duopoly - two co-dominant institutions presiding over a market, essentially cutting out all other competitors or outside influences.

Are the two big players friends or foes? One can make a case for both. Republicans and Democrats, Ford and GM, and even Magic and Bird - all dominant duopolies that symbiotically blasted and outlasted their competition. That is, of course, until the third party showed up - the new kid on the block. Traditionally, the third party, or its potential to arise from obscurity into the limelight, has been a great offsetting entity to the status quo of the omnipotent duopoly. Just ask the Tea Party, Chrysler, or Michael Jordan. These entities, the consummate "start-ups", all served to destabilize the ruling double-team, and thus helped democratize whatever industry they were involved in. As it turns out, this destabilization, a requisite force of the free market, serves to wipe up the cobwebs of industry stagnation, and create new avenues and vectors for ingenuity and prosperity. But not all third parties share in this benevolent intention. Some third parties have done the exact opposite. 

It might sound like blasphemy coming from a libertarian, whose inherent belief system is governed by the ultimate aspiration for democratization and equalization of opportunity; but, we need to reinstate the desired duopoly in medicine: the Doctor and Patient. Since the dawn of humanity medicine has always been a two-person dance. An elegant, professional, distinctly intimate interaction guided by altruism and professionalism on the doctor's part and self-preservation on the patient's part. This exchange of privileged professional services, the provision of healthcare from doctor to patient, does involve, however, an economic exchange as well. This is where the vultures and hyenas of society smell the blood. They’ve noticed something: an opportunity for profit and control. Insidiously, the third party of medicine, be it commercial healthcare insurance companies or government-run programs, has been let into the doctor's office, and predictably, has done nothing to improve quality or cost of healthcare. Third party payers have so entrenched themselves into the healthcare system, that they no longer serve as a typical “insurance” entities, but now serve as all-powerful administrators and “approvers” of medical care. The healthcare insurance industry is no longer used only for coverage of catastrophic events, but is now “approving” CT scans, X-rays, mammograms, and blood work, to name just a few. They’ve also been deemed authoritative enough to decide whether a procedure is “medically necessary”, all without ever meeting the patient. Now, how does this make any sense?

Patients need to realize that their healthcare insurance carrier is not in the business of caring – they are in the business for profit. Corporate medicine, that is healthcare controlled and administered by centralized, detached, omnipotent bureaucrats, ultimately leads to a frustrated and powerless workforce – the doctors themselves. Ultimately, the very people delivering healthcare are driven out of the business, both materially and spiritually. Now don’t get me wrong, one mustn’t blame the corporation for being a corporation. It is, after all, acting in its own best interest and well within its moral imperative. Profit drives it, and that is good. But the ballooning administrative control that third party payers have achieved has hardly contributed to an improvement in the quality or diminution of the cost of healthcare. In fact, this burdensome control only siphons money out of the system, away from doctors and nurses and towards middlemen and pencil-pushing bureaucrats. The federal government’s solution to the problem, the Center for Medicare and Medicaid Services (CMS), has an even worse track record than private entities. Medicaid and Medicare reimbursement fees are so abysmal (perpetually controlled by the flawed Sustainable Growth Rate (SGR) formula) that many doctors can't afford to take care of those patients, ultimately decreasing access to quality healthcare. Insolvency is all but an inevitability, and sooner or later, the system is headed for complete collapse. Dr. Milton Friedman once reiterated: “there's no free lunch” - to mean that nothing in this world is for free. Not any product and not any service. Sadly, medicine, as we know it in 21st century America, has become the last bastion of serfdom. A virtual expectation that, at times, the doctor work for free. It is, after all, a profession born of altruism and compassion….

So, how do we fix the problem? Let us reestablish basic principles. Let us return medicine back to its free market roots. But let’s not ask narcissistic, corrupt, temporary politicians to do this by legislative fiat or decree. Let’s just do it on our own. Let us not accept the status quo of the insurance healthcare fraud. Let us unshackle ourselves from their administrative hegemony and price point controls. Let us be sovereign, willing agents of the free market. Let us rise and fall by the merits of our professional actions and demeanor. Let us educate and empower our patients to act as their own advocates and take the fight to their insurance carriers. Let us get all the pretenders and imposters out of the doctor’s office. Let’s restore the fiduciary relationship between doctor and patient, and get back to the desirable duopoly.

About: Dr. Daniel Kaufman is a Board-certified plastic and reconstructive surgeon and a Surgical Facility Inspector for American Association for the Accreditation of Ambulatory Surgery Facilities. He is the founder and medical director of Discreet Plastic Surgery, PC, with offices in Manhattan and Brooklyn. He blogs at Medical Spa MD.

Hospital Administrators Are Not Always Honest

Guest post by John Di Saia, MD

Hospital administrators have an agenda that's not always aligned with yours.

I used to do emergency work at a hospital in a large chain. It was hardy profitable and became less so over time. When I moved an hour away I sought to limit my emergency exposure for obvious reasons. The hospital administration cited sections of the Bylaws and Rules and Regulations that mandated that surgical specialists take call. This was specified for Plastic Surgery and Orthopedics.

Later and entirely by accident, I found out that the Orthopedists were being paid to take this emergency call by the same administration that was citing those hospital documents. Essentially they were being paid to take call from 15 minutes away whereas I was required to take call for free from four times the distance. Needless to say I dropped that hospital after briefly entertaining legal action. So soon after my divorce I hardly wanted to enrich another attorney. They are much smarter about getting paid than physicians are. I did inform a contact at the local newspaper who passed on the story stating that the public doesn't really care if a doctor gets screwed over. I found that a bit amusing.

As the story evolved I extended my practice up the street not so far away and something similar almost happened again. This time the administration in my new acute care hospital sought to get into an arrangement with me to take call. They were very quick to stipulate that this arrangement was to be secret. It was to involve some kind of payment from the hospital. The thought left a bad taste in my mouth. Emergency call is a loser. I just stopped taking it.

The moral of this story is that you should not expect hospital administrators to be honorable people. Entering into any kind of business arrangement with them especially a secret one is liable to be unfair, unjust or just plain illegal. You might want to avoid that.

About: John DiSaia MD is a plastic surgeon and blogger who also writes at Medical Spa MD.

Non Clinical Revenue Generation

Guest post by Jordan Grumet MD

Although I mostly expound on the trials and tribulations of practicing medicine, for a guest post, I decided to write about being a small businessman. 

Running a successful private practice can be both difficult and time consuming.  With the recent passage of health care reform, many physicians fear the security of their current income streams.  As primary care doctors, we face the ultimate catch twenty two.  The better job we do, the less outpatient visits and hospitalizations are necessary, the less money that flows through our doors.  Talk about perverse incentives!  Many have thrown their hands up in the air and joined the local hospital or medical group.  For some of us though, the loss of personal freedom is a major concern.  

So what is the burgeoning physician/entrepreneur to do?  How do we continue to be captain of a ship that faces a tsunami of change?  For me, the simple answer lies in maximizing non clinical revenue generation.  

Over the years, I have established myself as a medical expert, nursing home director, and writer.  Each of these activities provides consulting fees that are more lucrative than patient visits, require little or no overhead, and develop new personal goals and interests.By diversifying my skill set, I have created a more stable and enjoyable practice environment.  Furthermore, my time spent in the clinic is more concentrated and busier than ever.  I no longer need to try to actively recruit new patients.

There are many different nonclinical revenue streams available to physicians.  Besides those mentioned above, there are opportunities with pharma, chart review, and biotech to name a few.  Either way, I no longer worry about the traffic through my exam room door.  Most importantly, I am able to practice parsimonious, appropriate care and still bring home a salary that I'm proud of.  

And I learn something new each day.

About: Jordan is an Internal Medicine physician practicing in Highland Park, Illinois. He blogs at In My Humble Opinion.

Effects Of Changes In The Medicare Physician Fee System

Guest post by John Di Saia MD

Relatively newly practicing physicians may not know that the Medicare physician payment system changed pretty substantially in the early nineties. This was by design.

The perception of those who designed this new system was that certain services were overpaid and others underpaid. It likely had much more to do with ratcheting down the costs of health care. As physician fees constitute only 10-20% of the entire equation, the wisdom of concentrating on physician’s fees to change the system is perhaps questionable. This is what was done nevertheless.

A cornerstone philosophy of the new system was that procedure-based specialties were overpaid. The physician fee system prior to this was based on usual and customary fees. This newer one based payments on a model that paid for a service at a uniform rate regardless of who performed it. While this seems fair on the surface, it had predictable effects.

Why would a surgeon with much higher overhead remove a lump in a patient if the new payment system put the procedure in a revenue negative position? The practice of surgeons removing certain lumps gave way to family practice and dermatology physicians removing many of them. These were the only specialties that under the newer system could turn a profit doing so.

The Medicare fee schedule economically regulates procedures in medicine. It also indirectly fed the growth of cosmetic medicine and surgery as this was the escape hatch many practitioners sought as the Medicare boom feel upon us. Surgeons interested in turning a profit quickly figured on what paid adequately and more importantly on what did not. As my grandfather told me as a young child, everyone needs to make a living. It is perhaps unfortunate that doctors do not discuss these matters with patients when telling them why they cannot offer a service. Is it really ever wrong to tell your patients the truth?

About: John Di Saia MD is a board-certified Plastic Surgeon and formerly (he didn't re-certify) a board certified General Surgeon as well. He also serves on the California Medical Board's Expert Reviewer Program reviewing cases of proposed negligence in the field. He blogs at CosmeticSurgeryTruth.com and is a Contributing Author to Medical Spa MD.

The Harvard Physicians Writers Course Is Time Well Spent

The 2012 Harvard Writers Course Starts Today.

Guest post by Diane Radford MD

Today marks the beginning of the 2012 Harvard Writers’ Course (www.harvardwriters.com) organized and led by Julie Silver MD (www.JulieSilverMD.com). 

Entitled Improving Healthcare Leadership, Communication and Outcomes Through Writing & Publishing, the course spans three days and enriches the attendee through lectures and workshops. Designed for physicians and allied healthcare professionals who write or aspire to write, the topics covered are wide in scope: understanding the publishing industry, how to write a book proposal, how to hone a “pitch” for your book, the art of storytelling, and how to make English move, and platform-building, being a few.

I have attended the course twice before and always learn something new. Ample opportunity is given to network with other writers, agents and editors. A highlight of the course is the oral book pitches, when authors each have 70 seconds to present their book idea to the audience, and receive immediate feedback form a panel of agents, editors and book coaches on its strengths and weaknesses. Alumni of the course, who have now seen their books in print — such as Jill Grimes MD (Seductive Delusions: How Everyday People Catch STDs), Jeff Szymanski PhD (The Perfectionist’s Handbook), and Julia Schlam Edelman MD (Menopause Matters: Your Guide to Living a Long and Healthy Life) — give personal insights into their respective publishing journeys.

Three- hour advanced workshops are given on social media (RustyShelton, www.sheltoninteractive.com), writing a book proposal (Julie Silver MD), maximizing creativity (Shelley Carson PhD), Memoir Writing (Leah Hagan Cohen), writing for your reader (Lisa Tener www.lisatener.com and Martha Murphy), and the craft of writing (Susan Aiello DVM,ELS).

I can highly recommend this course for any physician or health-care professional who wants to write or who writes but is unclear of the next step in the publishing process. Lessons I learned from attending last year I was able to put into practice leading to the development of my website and a presence on social media — platform, platform, platform.

About: Dr. Diane Radford is a Surgical Oncologist and Breast Surgeon at Mercy Clinic St. Louis Cancer & Breast Institute. Learn more about Dr. Radford at http://www.dianeradfordmd.com

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By Far The Most Common Conversation In A Hospital Is Complaining

By Tamara Moores, a fourth year medical student at Loma Linda University specializing in Emergency Medicine.

They tell me that I’ll change.

They always do.

In our first two weeks of medical school, freshmen students are assigned to shadow senior students working in the hospital. When I was a freshman, my senior student’s final comment to me was “Wow. You’re really enthusiastic… That will change.”

Now as a fourth year medical student, today’s version of the story was – “intern year will change you. You may look the same on the outside, you may portray that same bubbly, sunshine personality, but inside you’ll be different – harder, less tolerant, mean.”

They say it with confidence, they say it with authority, brooking no disagreement, allowing no doubt. Attendings, residents, nurses – they all deign to tell me my future – “there’s no way you can stay that energetic, it’s incompatible with a medical career.” Over and over I have heard this. As a medical student, I am supposed to listen and learn - to be guided by these wise elders. This morning when I heard the prediction for the 100th time, like always I politely listened with a half-smile. Yet silently my spirit roared “How DARE you smugly tell me the fate of my soul?! How DARE you justify your own insecurities about your passionless heart by attempting to degrade mine?”

Medicine is a unique environment. In my short foray into this time-honored, traditioned society, I have been buffered and shocked by the rampant negativity that oozes through the hospital walls. People seem to even take pride in their ability to bemoan their situation.

“Oh God, another consult from the ED, think they managed to even do a physical exam before calling?”

“That professor has no idea what’s on boards.”

“I can’t believe we have to be here.”

“This computer system is a joke.”

By far the most common conversation in a hospital is complaining. Tomorrow, try something different - stop and listen to the myriad people talking at work. The ratio of negative to positive conversations will overwhelm you.

Why is hospital culture like this? Shouldn’t a place of healing be full of warm emotions, positive thoughts, and uplifted people? Why is a ‘negative nancy’ the most common type of medical professional we meet? What are we doing wrong? These questions often come to mind during my workday. There is no easy answer. At the very least I know my top goal is to NEVER become that stereotypical cynical physician, and instead be the uncommon doctor with true passion for medicine.

So how do I accomplish this in such a caustic environment? Have no doubt, even at my current bubbly baseline, it is a daily war to maintain my heart for this career. So many physicians before me have fought this battle and lost. How can I succeed where they have failed?

A resident who I highly respect recently told me ‘be careful what you say, because talk patterns become thought patterns.’ This, more than anything, is my first defense against cynicism. It is SO easy to fall into conversation filled with complaints. These tiny conversations seem harmless, but over the course of a lifetime they shape your soul. Now at the end of my medical schooling, and at the cusp of residency, I am awed by the power of the spoken word. It’s undeniable - what we say both molds and reflects what we think.

Overall I believe the best weapon against developing permanent pessimism is to be deliberate in how we react to daily adversity. How do we respond to a floridly difficult, unpleasant patient? Do we moan about how annoying they are? Do we ruminate about how unfairly they treated us? Permit me to suggest a different response. Instead of focusing on how unjustly that patient has treated me, I instead try to feel gratitude. Whether or not it’s right, these difficult patients make me grateful that my life has not put me in their position. They must be really unhappy inside, to so poorly treat the people who are trying to care for them. When I am mistreated by an attending, I remind myself that they are but a momentary discomfort, and soon will be gone from my life. Over and over I find myself fighting to see the positives in my life. It is a deliberate, intentional strategy, which allows me to shine out with joy even in the little moments of the day.

I firmly believe that working as a medical professional can be a path to a life filled with meaning and passion….if we let it. Not all days are perfect, but most days I feel like I’m the luckiest girl in the world to be in my chosen career. The patients are interesting, my skills are stretched, and I feel fulfilled. Beyond these personal reasons, more than any other career, medicine reminds us how short and precious life is. We deal in broken bodies, lives cut short by car collisions, by strokes, by chronic disease. How lucky we are to be able to move our bodies without wheelchairs, to be relatively self-sufficient. Working in the medical field reminds me daily that everything can change in a moment. It is this acute awareness of the frailty of life, which makes me embrace life with so much abandon. It is this knowledge that gives me joy in the workplace, even during the rough days. To put it bluntly, life is too darn short to be grumpy.

So why am I reflecting via this forum? Perhaps because I hope that I am not alone in this fight. Perhaps I hope that by starting a discussion, we might nudge forth a change in the standard hospital culture. Maybe with forums like this, we can shift the caustic paradigm. Here’s to hope.

About:: Tamara Moores is a fourth year medical student at Loma Linda University. She is specializing in Emergency Medicine. https://www.facebook.com/reflectingthelights

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Facebook + Physicians

By Jay Scrub

Your patients tweet from your waiting room. They describes their symptoms on Facebook. They ask about that 'funny rash' on Quora. They looked you up on LinkedIn.

Your patients are engaging in social media - are you?

Not just personally, but professionally - the expectations have changed. Medicine ultimately is a service industry, and like all service industries, the expectations of our customer, our patients, have changed. They are online and expect us to be as well. The question facing most practices is, to what degree? With practices stretched thin already managing work in the office, how can they devote resources to having an online presence?

These questions do not have simple answers, but like any medical problem you encounter, the first step is to gather more information. Think about your patient population - how active online are they in general? Clearly, there will be a big difference between a pediatrics practice and a geriatrics one. If your patient population is quite broad, another approach is to [drum roll] ask them! Many patients would be happy to let you know where they look for medical information and what ways they find convenient to communicate with your office.

As you have determine what your patients want, you also have to ask yourself how much are you willing to devote. In this day and age, being absent online is no longer an option. At a minimum, you should post basic information about your practice such as the address, telephone number, and office hours. I highly suggest that you have at least a static website that offers this information, and definitely make it accessible on sites that people use to find locations such as Google Maps, Bing Maps, and Yelp.

However, this post is about 'social' media, and static information is not very social. Look into creating a presence on Facebook and Twitter. You will have to judge whether you want these channels to be more one-way, with patients sending information to you, versus two-way with you or your office actively responding. You also have to judge how 'medical' you want your communications to be, keeping confidentiality and liability issues in mind. Avoid discussing specific medical issues in these forums. However, they function great for communicating general health tips, answering general health questions, and providing specific office information such as hour changes or new medication / treatment options available. Images showing when preventative care should be performed, or basic management algorithms, can be very helpful for patients. If you are particularly intrepid, ask a patient with a 'success' story if you can share their story on your social site. Draw your patients into the conversation with you.

Social media is an uncharted territory for most physicians so don't fear - explore! Learn what kinds of pages and accounts work best on these sites. Try different types of comments and posts. Including engaging content that your patients/fans would want to share with each other. In the social media world, something being 'viral' is a good thing! Help your users catch the bug! Chart your own course in the social media waters. Your patients will benefit and sing your praises - online and off.

About: Jay Scrub blogs at http://www.ScrubNotes.com, a site for physican trainees of all levels discussing topics for success in medicine.

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