It is true, some slice of this 90% are employed by physicians groups, self incorporated, and their employers may be other doctors, but the doctors in this 90% are now answering to someone who tells them if they are seeing enough patients, fast enough, if they are being "productive," which is variously defined by either "the body count" i.e., how many patients they see each day, or how many dollars those patients' insurance companies fork over. "Billable hours" for the lawyer are unheard of for the modern physician. What counts is something over which he has no control, how many dollars the insurance company decides to pay.
The Phantom spoke with a young physician recently and she as happy because she had got a new job. She is only 6 years out of training and during those 6 years she had never managed to see more than 10 patients a day; at her new job she was told she would have to see at least 18 patients a day, but she was optimistic because the new job had electronic medical record, which meant she did not have to dictate into the voice recognition systems she hated and then write a hand written note to supplement that. She was also told that new patients, which currently take her an hour would be interviewed for their history by a "mid level" meaning a medical assitant or a nurse or a nurse practitioner and that meant that by the time she stepped into the room with the patient all that would remain to be done would be to look over the medications and make any necessary adjustments, which she could easily do in 10 minutes.
Now, this is a very personable young woman. When she enters an exam room, she is typically smiling a rbig, dimpled smile and she has a wonderful voice and greets patients heartily, "Hi, Mrs. Smith. How are you today?" But all that will now be followed with a few minutes of medication review, analysis of how the blood sugars have responded to insulin, suggestions for changes, and a hearty handshake good bye.
There may be time for a perfunctory glance at bare feet--feet are vulnerabilities in diabetics--but not likely for a listen to the heart or lungs and certainly no scan of the skin for melanomas or skin cancer--she is getting paid for a diabetes visit, not to save lives.
So this modern doctor, who has vast medical school loans to pay off, is happy. She will be making more money and the basis on which she can make more by seeing more patients is clear.
She will no longer do the sonograms on thyroids because these are not reimbursed well enough to justify her spending 20 minutes doing this, so the patients will be made another appointment with Radiology for that. The modern doctor will review this sonogram on the computer and if a biopsy is needed, she'll schedule the patient to come back for that--the patient's 3rd visit. The biopsy is paid well enough to justify her time. But if the biopsy is not quick, if time runs out, the doctor may cut the visit short--she'll do only one of the three nodules and reschedule the patient for the rest, and the clock will start ticking again and the billing will go up.
So the modern doctor is happy. She keeps those patients moving on the assembly line, keeps plugging in those maximized billing codes and the patient is scheduled and rescheduled and she has been seen 5 times for what the modern doctor had before done in a single visit.
The lingo for this is "RVU" or return visit unit and the modern doctor seeks to maximize the RVU's because that is the basis on which she (or he) is paid.
Somewhere in all this, the patient has got lost. Or, if not lost, shuffled.
This will all be more efficient, from the point of view of the doctors and the billing department. And none of this has been driven by Obamacare. This was happening before Obamacare and is accelerating quite apart from Obamacare.
It is happening because medicine is now thoroughly, unapologetically commerce now.
Heaven help us all.
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