Misdiagnosis: The Red Wedding for American Physicians

When Americans complain about one failing or another of the American healthcare system today, they typically find the demons where they want to find them: For those who hate Obama for, well for being Obama, every annoyance, every absurdity has one root cause: Obamacare. For those who resent rich doctors, it all comes down to arrogant, greedy doctors.  For others, it's the pharmaceutical companies. Pick you own devil.

Over the past decade the rich, greedy doctor story has regressed as people see doctors regressing into the middle class. As in many other things about the American health care system, American medicine has been drawn by the strong, ineluctable gravitational pull toward the state of where the British medical system was 40 years ago.  The median salary for pediatricians, primary care doctors, depending on the part of the country is between $80 and 100 thousand  a year, about what the owner of a couple of McDonald's franchises could make.  While there are still some specialties producing millionaires, the doctor's house is no longer the biggest in town, if it ever was.

There are many reasons for this regression toward the mean in doctors' economic lives, some of which are rooted in efficiencies.  The parts of a doctor's work have been analyzed, picked apart and the systems which form the patchwork quilt of our largely unplanned American system have been divided--so now most of the sore throats, rashes, headaches, nausea are seen by nurses, nurse practitioners, or the new category "physician assistants," people who did not have to be at the top of their high school and college classes, people who invested only two to three years of post college training before starting practice.  There is some efficiency and wisdom in this trend, but it is not an undiluted virtue.

Recently, the Phantom witnessed another part of this story, as he watched the disintegration of the best internal medicine practice in his small New England town.

This was a practice in which everything was done right. Before any patient was referred to a consultant a thorough, highly competent and efficient evaluation was done and once the decision to refer was made, a letter of introduction to the consultant was sent, so the consultant knew exactly what the question was. Phone calls to consultants, nursing homes, patients and their families kept lines of communication humming and vibrant.These doctors did far more than triage and turfing, i.e. hearing the complaint and sending the patient off to a dozen consultants. These doctors did what medical school and years of experience taught them to do--they did real medical care.

The group, which included six physicians, four full time male physicians and two part time female physicians saw their own patients, many of whom they had followed for twenty years or more, in their office from 7:30 AM until 4:30 PM, and then they walked across to the street to see their patients in the hospital.

Even when the hospital hired "hospitalists" to take care of hospitalized patients, these doctors saw their own patients in hospital.  "Being in the hospital is often the worst place a person can imagine finding himself," one of these doctors said. "When they are sick and frightened, they want to see their own doctor."  

As hospital stays got cut shorter and shorter, the number of patients this group had in the hospital dropped precipitately--rounds were no longer on 12 patients but on 2, and those were likely to be on Medicare patients, for which the doctor got $35 to $48 dollars a visit. Oddly, the time spent in the hospital did not drop commensurately. Chasing down lab results, nurses, consultants, radiology reports, X rays, talking with the patients' families still kept these doctors in the hospital for hours, for that $48.

Eventually, it came down to a choice: "I could spend from 4:30 to 6:30 PM in the hospital seeing two patients for $96 or I could see 6 more patients in my office, usually bringing in about $480."  The office, in terms of economic reward was obviously the place to stay. But these doctors did not want to "abandon" their hospitalized patients. The kept walking across the street.

Ultimately, the dollars and cents brought them to a decision. With rising office rent, staff salaries and health care benefit costs, with falling insurance company reimbursements and more staff needed to deal with the different insurance companies, it got more and more difficult to meet payroll.  

The practice, after much agonizing, sold out to a big hospital and medical system chain and they became employees. They promised, under a "non compete" clause, not to practice within 20 miles of their office if they decided to leave the employ of the company.  So, if they parted ways with the company, the company "owned" the patients these doctors had cared for for 25 years. They had crossed a Rubicon. Once hired, they could never resume their own private practice again.

At first, they were happy; they could stop worrying about money, got  their monthly paychecks and just saw their patients.

But when time came to renew their contracts, they were told the company which employed them was shifting to a new "model" in which the financial risk of the practice was shifted to the doctors. The overhead of the practice, the rent, staff salaries, photocopying, billing, supplies would have to be met by practice collections before the doctors could be paid from what remained.  The company had not been particularly competent in negotiating deals with insurance companies, so the income actually collected by the practice had fallen, despite increased billing totals. 

"It was the worst of both worlds,"  one of the docs said. "You could no longer control the costs of practice, and you could do nothing to increase the income."

In fact, the company added another physician to the practice when it was not clear there were enough new patients to justify it. "We need to increase market share," the doctors were told. 

The doctors were particularly appalled to read the company, nation wide, had been hugely profitable as they were cutting the salaries of the doctors. A new head physician had been hired in the company's central office in a distant state, at a salary of $15 million a year.  The doctors tried to contact him but he replied he only talked to "market leaders"  and that he was considering "reformulating my communication strategy" but that once he had figured out how to "leverage our scale across similar services" he would, possibly, get back to them. He was very busy figuring out how to achieve dominance of practice and market identities, so he could not project from home base to the local practices just yet.

"I had no idea what language he was speaking," said one of the doctors.  "I think it must have been MBA speak."

One doctor simply quit. Two of the doctors found new practices in North Carolina.  "I've got, I hope, 20 more years to practice," said one. "I just cannot deal with these people."  This doctor had been an anesthesiologist for about ten years, earning among the highest salaries, working regular hours, bored stiff. He re trained for internal medicine, did office hours, rounds and saved lives, and loved it. But the company defeated him. 

He found a new practice and he moved his family from New England to North Carolina. 

"It's a wrenching experience," he said, as he packed up. "But what else could I do?"

His is a choice many more of his kind will have to face.  He is like one of the Stark family in Game of Thrones.  He chose honor and a code and that's what did him in: He was invited to the Red Wedding.