By ALLAN DOBZYNIAK, MD
The collective “wisdom” promoted by the MBAs, nouveau healthcare experts, politicians and bureaucrats can be condensed into a singular thought: Doctors were part of an anachronistic model which was condescendingly labeled a “cottage Industry.” According to this expanding array of mutually anointed experts, this was a stupid residual from a previous era. The truly operative word here is industry. Then, as an industry, it needed to be aggressively nudged into modernity as these wizards envisioned it. Included in this group-think vision was the caveat that turning the physicians’ practice of medicine, a profession, into an industrial model laden with regulations, mandates, rules, care models and protocols was mandatory. But could it have been the dollar signs in the eyes of the industrialists when gazing at 16 percent of the U.S. economy attributed to healthcare that was originally and continues at present to be the salient motivator? Add to this the enormous transfer of power to the federal government.
Those fortunate enough to get in on this potential bonanza certainly have prospered. The exponential increase in government healthcare bureaucrats with their lavish salaries and benefits, the hospital management aristocracy, the health insurance companies, the IT companies selling their ludicrous fantasies, the pharmaceutical enterprise with its layers of profiteering and of course the trial lawyers always vigilant to new financial opportunities have all prospered as each has taken a bite out of the blossoming financial and power laden cornucopia. Now we have hospital systems consolidating in their battle with insurance companies, which themselves are merging with pharma, to directly compete with hospitals by extracting previous inpatient dollars to outpatient initiatives.
This has produced the increasing movement of physicians, buried in valueless, unproven nonsensical schemes that magnified their overhead and sapped their productivity, to hospital employment or incorporated into conglomerates funded by venture capitalists as these businesses bought their practices. Physicians’ professional organizations have been complicit in inflicting MACRA on the medical profession. MACRA is a barely understandable moving target virtually guaranteed to reduce physicians’ incomes as the law satisfies its budget-neutral requirement. [Editor’s Note: The Medicare Access & CHIP Reauthorization Act is a law regulating how the Center for Medicare and Medicaid Services pays physicians. The act pays increased or decreased rates based on a variety of criteria. MACRA has drawn considerable criticism from the healthcare community based both on its structure and program details.]
Hospitals utilize what may be one of the single most corrosive forces ever devised, the relative value unit (RVU). What employed physician does not eagerly await these “dashboards” of “value” showing his or her productivity including how well they stack up with other doctors locally and even across the country? This wondrous array of colorful graphs ostensibly tells a physician’s employer if he or she is a hard worker. Where is listening to patients, examining patients, counselling patients, teaching colleagues or even hugging a patient reflected in the RVU? Hint, it isn’t. Physicians must make few waves, select the best templates on their EHRs so that billing documentation is maximized and produces many lucrative procedures to optimally fulfill the RVU productivity demands. But if a physician works slowly, deliberately and conservatively, creates clinically valuable narrative notes or, “God forbid,” is thoughtful and frank about silly policies, he or she is an outlier. Now really, does productivity as measured by the RVU really have a place in rendering medical care?
Then there is the matter of masters. The doctor now answers to an employer, to an insurance company, to a government bureaucrat and finally to a patient. Somehow, one must question the appropriateness or even the morality of such a bastardized system.
While all of this money from 16-plus percent of an $18 trillion economy is being distributed among the industrialists, physicians are being taught altruism. What a wonderful tool has altruism been to regulate physicians’ singular and crucial role relative to the entire industry to irrelevance both as practitioners and as entrepreneurs.
In retrospect, maybe the good old “cottage industry” with the simplicity of a valued interaction grounded in the relationship of a doctor with a patient may have actually been superior to what exists now and where the profession seems to be heading in its future. Don’t buy into the predictable gotcha response by the elitists, “American medicine was never great.” Of course things in medicine’s past could have been better. But medicine will never be perfect. The mistake though is to abandon certain ideas from the past and eventually forget them when racing toward a questionable future. In no way is this meant to imply time travel back to the “good old days.” It sometimes seems that the more healthcare is forced to change, the more screwed up it becomes. The more screwed up it becomes, the less chance remains for reasoned inclusion of still-valued traditions of the past. It is incredible the changes in healthcare that have resulted from unproven assumptions and continue to be used as a basis for abandoning what has worked before. Physicians still have choices; options still exist. But the window is closing and will do so more rapidly with the passage of time. Inertia, apathy and finally surrender are traits of those “burned out.”
Remember, ink and paper still exist and printed notes cannot be hacked, not to be taken in its literal sense but for what is implied.