A vascular surgeon at Portsmouth Regional Hospital mentioned in his profile in the catalog of doctors that he had "trained with Dr. DeBakey," which caught the Phantom's attention. Everyone else listed their medical school, residency and fellowship training program but for this guy saying, "Baylor, Houston Methodist" would not do, as he may have thought that wouldn't mean much to New Englanders, but that DeBakey name would. This particular surgeon became locally famous for never doing surgery. Mostly, he did not respond to consult requests, but on the rare occasions he did respond, he declined to operate. This can get the attention of the ICU staff when faced with a patient with a cold blue leg needing an arterial bypass. At his two year review, it was pointed out to this surgeon he had done only two surgeries and that did not justify the expense of his salary, and he disappeared.
That sort of extreme desultory behavior is unusual in medicine and, in particular, in surgery, but it is likely the sort of story administrators love to trot out to show how important it is to have administrators riding herd on doctors who would otherwise not show up to work.
In the Phantom's own department were two other doctors and one, a woman with two kids below the age of three, saw patients Monday through Thursday but on Friday she showed up in scrubs (rather than a white coat and dress) for her "surgical day," during which she did thyroid ultrasounds and, when necessary ultrasound guided needle biopsies of thyroid nodules. On those days, she saw only about four patients, rather than the usual 20-25 and she was home to her kids by noon. She missed days when her kids got sick and she was out for 3 months after the birth of one child. So, at her two year review it was pointed out that the number of dollars she generated compared to that of her two colleagues was substantially less and her salary would be cut.
She immediately resigned, in a huff, having stayed 3 years at this practice and she moved on. In that, she was in the mainstream of her cohort--many if not most young women physicians moved every three years when they learned they would not receive a raise in pay.
So, yes, the Phantom is aware that not every doctor is driven and a work horse. The idea that we are workers like any other sort of workers, and we move from job to job, from patient panel to patient panel based on the dollars is now accepted as a fact of life.
On the other hand, there are instances where the profit motive drives medical practice into dark places.
The hospital in Portsmouth was run by a for profit corporation. It was set up as most systems were set up in those days: the hospital itself was flanked by two office buildings with doctors' offices which contained practices covering most medical specialties: including neurology, rheumatology, oncology, endocrinology, and primary care. Unlike cardiology and gastroenterology which have lucrative procedures to bill, these "cognitive" practices broke even or even, some years, lost a little money in billings v overhead.
The general concept is that the office practices "fed" the hospital, sending patients to the ER, to radiology, to the laboratories and all the other "in patient services." While doing so, the office practices provided care for the communities which surrounded the hospital.
But on day, the administrators in Nashville looked at the corporate offices and they shut down the break even practices and saved a lot of overhead--office rent, staffing, phones, supplies. Primary care physicians were replaced with nurse practitioners and physicians' assistants, who cost less and could be booked for a patient every 10 to 15 minutes.
It turned out, the hospital could be "fed" by a few Urgent Care Centers placed in neighboring towns and the volume of hospital business pumped along just fine, with no drop in ER visits or radiology studies or lab studies ordered.
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| Mad Cow Disease |
The administrators who did this were not bad people, certainly not monsters: they were simply doing their jobs, which was to increase profit, to increase the value of the corporation for the shareholders. They were, we heard later, "heroes" back in Nashville for having cut all that overhead.
Of course, all those patients with arthritis, diabetes, cancer, chronic lung disease back in Portsmouth, New Hampshire and in the surrounding communities were now bereft of care, but that was not the job, the mission of the administrators in Nashville, whose job was to increase profit.
One day, a patient showed up at the Phantom's office with a letter from his insurance company informing him they would no longer cover the cost of his insulin pump and its supplies. His type 1 diabetes had been spectacularly well controlled for five years on his pump, with HbA1c levels, which measure overall blood sugar control in the normal range. But that did not please the insurance company. Somewhere, someone in the insurance company, reviewing the medical records we dutifully supplied the company, saw these normal numbers and said, "Oh, these numbers are all normal! We do not need to continue to pay for someone who is now normal, who no longer has disease!"
As if "tight glycemic control" is actually "cure."
The Phantom tried to telephone "the company," between patients but got nothing but the "your call is very important to us, please hold on," and he assigned a medical assistant who wound her way up the line of clerks and "patient care facilitators" and "community health advocates" and kept asking for a doctor for the Phantom to speak to--a "peer to peer," exercise where one doctor talks to another, the treating doctor and the insurance company doctor. It turned out the patient's insurance company had subdivisions and the part that insured the diabetes might have been different from the rest of his health insurance--it was never clear. In the end, by the time the Phantom's medical assistant went home at five p.m., having not been able to attend to any other patient that day, leaving the Phantom to call in prescriptions and do all the clerical stuff she usually did, and slowing down the machinery of the office that day so patients were kept waiting impatiently, there was no solution to the problem.
Delay, deny, desist.
So, the health insurance company, like the company which ran the medical practices at Portsmouth, was profit driven. Private enterprise, devoted to reducing costs and keeping a tight rein on the budget.
There may be other services which are not best run by private enterprise in search of keeping their organizations lean and mean: power companies, water companies, highway and bridge maintenance, meat and food inspections, fire fighting, police, coast guard, the Navy--things where cutting costs undermine the basic provision for the common good.
But somehow, all these other "public services" are accepted as better organized to service the public good rather than to serve profit.
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| Alexandre Yersin, Conqueror of Plagu |
In America, health care not for profit is communism, socialized medicine and a sign of impending doom.
And, oddly, the very people most likely to rail against socialized medicine benefit from their own socialized medical care: military medicine, VA medicine and health insurance for US Congressmen and Senators (which is provided through an insurance so generous as to be basically government owned.)
So, we beat on, boats carried by the current, rudderless, drifting past riverbanks, headed toward the sea of oblivion.
