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| An Effective Leader |
If a hurricane followed by twelve tornadoes ripped through the state of New Hampshire tomorrow, some people would blame it on Obamacare.
The fact is, medical care is changing in ways which are not (yet) apparent to the consumers of health care, and only a small proportion of those changes is going to be affected by Obamacare.
Which is not to say the health insurance industry has not been a major force in the changes. Health insurance, the money people have driven doctors off the field over the past ten years. Nationwide only about 10% of doctors are self employed, independent, hang-out-your-shingle free market, Ayn Rand control your own destiny figures any more.
Most doctors are employees of either large corporations (hospitals, Kaiser type organization, commercial companies like Hospital Corporation of America, or large group practices).
Insurance companies, and to a much less extent, Medicare, have so reduced payments to doctors, the vast majority found they could no longer pay their rent, meet their payroll and earn a living, so they flocked to employed status.
What they found when they arrived is that their new masters demanded more and more patients seen per unit of time.
Administrators began to break down the tasks doctors do during their day, and dividing up these tasks to be done by high school graduates. Need a skin biopsy--have the dermatology tech do that. Costs less. Need a stress test, a chest tube, almost any in office procedure, hire a tech. Need a visit to adjust your insulin doses? A certified diabetes educator, might be a dietician, can do that. Need your coumadin dose adjusted, a nurse can do that.
What has been left to the doctors, the administrators argue is the stuff only the most expensive member of the team can do--read the X ray, listen to the history and order the diagnostic tests and the medication or the referral.
So far, all this, it may well be argued, increases efficiency and decreases costs.
Except when it doesn't: Nurse practitioner and physician assistants now see patients for things like possible hyperthyroidism, angina, inflammatory bowel disease, multiple sclerosis, Lyme disease, peripheral vascular disease, and they often order the wrong or most expensive tests which means we are in the position of being penny wise, (cheaper visit) but pound foolish (unnecessary referral to a consultant $500, $4000 MRI, visit to the ER $1000).
"Medicine is too important to be left in the hands of doctors," was the jarring line of the 1970's. It was very punchy and anti authoritarian and it was widely quoted, almost a mantra.
Trouble is, that line has turned into a policy. Now the doctors no longer have much at all to say about how medicine is delivered.
It hasn't been and won't be pretty.
Yesterday, the Phantom met with the CEO of his hospital and a number of administrators from the corporation which runs the practices connected to the hospital. These practices "feed" the hospital system. They send patients, laboratory, radiology referrals to the hospital. They, in business terms, bring the customers through the front doors.
The CEO said the purpose of the meeting was to open communication between the doctors and the administration. When the doctors started talking about the problems the practices were having, about the loss of critical doctors, about why they could no longer refer patients to the hospital, or send them to the emergency room, the CEO of the hospital said she did not want to hear about those problems.
She had problems of her own. She had not been able to meet her budget for the past 3 years. The doctors had been trying to tell her about why they were sending fewer and fewer patients across the street to the hospital, but she did not want to hear about any of that, she said. The problems in the practices across the street referring to her hospital were not her problems, she said. The practices belonged to another administrator. All she cared about was the hospital.
"So, if you manufacture cars, and the dealerships which sell your cars all over the country are closing down, that doesn't bother you?" someone asked. "All you care about is what is happening in your factory?"
The CEO did not get the analogy.
The CEO said the purpose of the meeting was to open communication between the doctors and the administration. When the doctors started talking about the problems the practices were having, about the loss of critical doctors, about why they could no longer refer patients to the hospital, or send them to the emergency room, the CEO of the hospital said she did not want to hear about those problems.
She had problems of her own. She had not been able to meet her budget for the past 3 years. The doctors had been trying to tell her about why they were sending fewer and fewer patients across the street to the hospital, but she did not want to hear about any of that, she said. The problems in the practices across the street referring to her hospital were not her problems, she said. The practices belonged to another administrator. All she cared about was the hospital.
"So, if you manufacture cars, and the dealerships which sell your cars all over the country are closing down, that doesn't bother you?" someone asked. "All you care about is what is happening in your factory?"
The CEO did not get the analogy.
Finally, one doctor said, "Can you hear yourself? Don't you hear what you are saying? You are saying you are here today to establish communication, but you do not want to hear anything we are saying. Is there something wrong with this picture?"
She did not understand that comment and she went on to say she thought we needed to set up a committee to improve communication with the doctors.
One of the other administrators noted doctors do not attend the committee meetings because they are not paid for committee meetings and they insist on seeing patients, for which they get RVU credit toward their pay checks.
One of the other administrators noted doctors do not attend the committee meetings because they are not paid for committee meetings and they insist on seeing patients, for which they get RVU credit toward their pay checks.
Eventually, the patients will feel it. Right now, it's just the doctors.
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