Doctors as a Commodity: the Ruin of Modern Medicine?

Did you ever wonder why doctors are reimbursed on the same fee schedule regardless of their experience, qualifications, knowledge, expertise, or interpersonal skills? Why is it that lawyers, teachers, businesspeople, military personnel, hospital administrators, and virtually every other person in our nation is reimbursed for his or her services on the basis of qualifications and experience, yet physicians – arguably the most highly trained group of the lot – are not? Examine this hypothetical (yet common) scenario. Joe Thomson graduates at the bottom of his medical school class and then completes training in a sub-par general surgery residency. His parents, though not highly educated, are very wealthy – they earned their fortune flipping houses in the early 2000’s. Because of an unforeseen turn of events, they were forced to sell their house-flipping empire just before the market crashed. Fortune indeed smiled upon them. Not having benefited from higher education, they had always had high aspirations for their only son. And so when Dr. Joe was at long last a licensed general surgeon, his parents wanted him to practice in the finest locale. They rented a beautiful Brownstone in Manhattan just across from the most highly regarded general surgeon in the city. And, they employed their marketing skills to spread the word about their up and coming son. Shortly after opening his practice he was called to the Emergency Room to care for a patient who required an extraordinarily complex surgery. This particular surgery is long, intricate, and carries a very high complication rate. Given the mandatory call system in his hospital, it was however the young surgeon’s turn to be “up at bat.” The accomplished surgeon across the street had already done well over 100 of these surgeries while our young doctor had yet to perform a single one on his own. (He had assisted in 3 during his five-year residency).

There are two issues to consider here. First, indisputably the unwitting patient would be better served with the far more experienced surgeon.

Second, both surgeons – one with no experience while the other a veritable expert – will be reimbursed exactly the same for this very difficult operation. You see, the doctors are a commodity – pork bellies, concrete, orange juice etc. Their skills are ostensibly indistinguishable and therefore interchangeable. Now imagine you’re the patient. Which doctor would you choose? If given the opportunity (which you don’t have under current insurance restrictions) would you pay more for one over the other? I know whom I’d choose, even if I had to take out a loan, skip vacations, work extra hours and the like. Here’s an added irony. The experienced doctor is on faculty at a medical school. His hard-earned skills are so great that a competing private hospital purchases his practice (and him), thereby increasing his income three fold. In sum, in order to make more money he left his position at the academic institution where he had used his superior skills to train young doctors. Within two years he becomes so highly respected at the new hospital that he’s advanced further, to the position of hospital CEO. Now he truly earns a hefty income. But, he no longer practices medicine. To “get ahead” monetarily, he had to leave the pool of expert practicing clinicians whose sole purpose is to help patients. To earn more money, our great surgeon had to stop doing surgery. He had to become an administrator.

I know it is considered indecorous for doctors to be concerned about money, but when our incomes fall while expenses rise; when we find it difficult to put our children through college or save enough money for retirement; when we cannot foresee how we will ever repay our college and medical school loans; when we lose our voice in how we are compensated; we have no choice but to become “normal” people and consider our incomes and how to best maintain and even grow them. In truth there is nothing inherently wrong with physicians’ focusing some attention on how much money they earn. In the past though doctors earned enough so as to not care about reimbursement. Their financial contentment yielded great dividends; they devoted all their free time to bettering themselves as physicians. They devoured journals and took medical courses; attended meetings and discussed interesting cases with their colleagues. Though some physicians still practice in this vein, many do not. Instead, most doctors today read Medical Economics and The Wall Street Journal, watch financial news on television, read books about alternate methods to make money, and carefully plan their premature exit strategies from the practice of medicine. The state of Medicine today is nothing short of depressing.

Non-physicians probably won’t want to hear what I’m saying. They might quip that doctors should be above money or that doctors make more than “enough” as it is. Be that as it may, the reality is that as a consequence of changes in medical economics as well as an explosion in the bureaucracy involved in private practice, many of the up and coming “best and brightest” are flocking to finance and business, and away from medicine. And that will leave us all at a distinct disadvantage when we seek and require top quality doctors down the road. Like it or not if we hope to bring back the doctors of yesteryear, we must face facts and acknowledge why so many doctors today are unhappy. We must identify what it will take to rejuvenate the medical field, and make it once again an enticing and challenging goal to which our young will aspire.

Learn more about preventive cardiology at www.preventivecardiologyinc.com.

For more information more about essential vitamins and supplements visit www.vitalremedymd.com.

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Doctor’s Prescriptions for Their Patients: Old Frustrations Persist

In a perfect world with boundless resources, patients would always have access to every doctor’s prescription. But our world is not perfect and our nation is in deep debt. Consequently every day doctors across the country receive denials for medications and procedures that we have prescribed. We know our patients need these medical interventions yet our hard earned positions as practicing physicians (requiring decades of study) are no match for the far less qualified employees of insurance companies. Oftentimes our prescriptions are lifesaving. Yet we are told patients can’t have what we’ve ordered. What we have ordered is simply “too costly”. We are forced to choose something else, even if it is an inferior approach and leaves our patients – those people we have all sworn oaths to protect – relatively unprotected. So, with resources limited to such a degree that we have lost access to solutions we know to be beneficial, what are doctors and patients to do? Let’s look at a disorder deserving great attention and intervention; yet oftentimes remaining hidden in the shadows. The disease is called FH (Familial Hypercholesterolemia) and it occurs in about 1 out of every 200 people.

One of the disorder’s characteristics that makes it difficult to diagnose is the wide variation in how it manifests; some people have LDL cholesterol levels well over 200 (I’ve seen levels over 500) while others are not so badly impacted. Some patients have heart attacks in their teens while others never experience such premature disease. One of modern day medicine’s most well established “facts” is that the lower a person’s LDL, the less likely he or she is to have a heart attack or stroke. Now consider those individuals with FH in whom we simply cannot, no matter how hard we try, adequately reduce their LDL utilizing insurance approved modalities such as statins and dietary modifications. Such people may have already suffered heart attacks at very young ages. They are at extraordinary risk for a future heart attack or stroke. Yet, their insurance carriers still often create impenetrable barriers for access to additional medications as well as LDL apheresis, a method that was FDA approved in the 1990s, and lowers LDL by a whopping 70%. Carriers bemoan the costs of the medications or procedure and cite a lack of adequate “outcome data” as their reason for denial. Though doctors explain that it is now accepted as doctrine by lipid experts across the globe that lowering LDL by any means provides dramatic CVD risk reduction, they remain intransigent. We share our knowledge of Mendelian Randomization studies, which have proved beyond a shadow of a doubt (in the framework of present-day science) that lowering these patients’ LDL levels will vastly decrease their chance of suffering repeated heart attacks, strokes, stents, and bypasses. Still their ears and minds are shut. We, the doctors, are powerless. And our patients suffer the consequences. And, compounding the problem, there is currently active consideration among insurers to make it even more difficult for patients to receive LDL apheresis.

The New Year has just begun and my colleagues and I have already received a plethora of complaints from patients bemoaning the fact that their insurance carriers have increased their medication costs to such a degree that for many they can no longer afford to take them. What will happen to these patients? Will they develop unnecessary heart attacks or strokes? Will they need unwanted and otherwise preventable procedures like bypass surgery and stents? I do worry they will fare less well than had they been permitted to follow the care so cautiously outlined by their treating physicians. And medical evidence does support my concern. I believe an outcry from patients is needed. Doctors will continue to make our case, but until the voices of worried patients achieve adequate volume, I fear the status quo will reign.

Learn more about preventive cardiology at www.preventivecardiologyinc.com.

For more information more about essential vitamins and supplements visit www.vitalremedymd.com.

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