Thursday, July 9, 2009

Medicine as a business

Although this is not specific to geriatrics or palliative care, this is an eloquent article that raises the real-life health care (perhaps more appropriate to say 'economic') environment that we now practice in.

http://www.nytimes.com/2009/07/07/health/07essa.html?_r=1&hpw

We may enter and even graduate from medical school with altruistic qualities of caring for the patient, the whole patient, and family (and never think about money). Certainly those of us entering geriatrics and palliative care lean farther toward this direction as evidenced by the fact that most geriatric specialists are paid less than internists who don't have the additional training.

This article strikes me as particularly poignant as the last 2 years of my post-training 'career' have been filled with countless examples of how the dollar impacts the day to day care I (and other physicians) provide. Here are just a few examples:

- Every month since the start of 2009, the low-income community health center where I work sends an email blast about where our clinic stands on our budget, how many patients we've seen, where we need to go to survive (due to state budget cuts and previously insured patients losing insurance but whom we continue to see). Every provider in my clinic has made efforts to increase visit numbers (starting earlier, finishing later, squeezing in more double books, scheduling patients during 'lunch') to ensure that we can enroll and see more medicare and medicaid patients to cover the services we provide to our uninsured. As physicians, each month we spend some time staring at a profit & loss spreadsheet.
- The primary home health agency we collaborate with has just collapsed 3 offices into 2 to save money and consolidate services.
- A hospice agency we work with closely has tightened up their assessments of the eligibility criteria for hospice services. I have never referred a patient to hospice and been 'rejected.' And suddenly I was called by the hospice that a patient I referred with dementia, comorbidities, and who couldn't possibly be more cachectic was not appropriate for hospice "at this time" because she still "eats well" (the very little amount that she eats). Having worked with this hospice many times and talking to this nurse, I feel confident this decision was not based on anything medical but was entirely economically driven by their own need to survive.
- A nephrologist I know who completed his fellowship a few years ago and entered private practice tells me the greatest learning curve he confronted upon leaving academia was that "everything is a business." From the most pessimistic perspective, referals to and from physicians may be more about 'staying nice' than the quality of the care. The most profound example of this for him, and me, was when other doctors in the hospitals where he consulted advised him to "stop telling patients [their prognosis was poor]" and that he did not recommend dialysis because these other physicians would lose billable encounters and procedures if these patients transitioned to palliative care.
- In surveying several geriatric practices around the country--representing multiple care models and financial structures--with the exception of a rare few, the majority of geriatric primary care and house calls practice do not survive on their own. Most require financial support and subsidies from institutional care (eg. hospital revenue or larger medical center support; nursing home care and directorship, etc.), grants, Medicare demonstration project status, etc.

Where does this leave the state of our health care system?
Well, short of the need for health care providers to remain engaged in health care reform and ongoing policy discussions, it raises for me the question of whether medical school training (and/or residency training) should do a better job of teaching our future workforce how money flows. Yes, on the one hand a physician who has easy access to imaging and tests will use these services more, but perhaps, also, a physician who lacks understanding of the basic principles of Medicare, Medicaid, insurance, etc. will also be more likely to use unnecessary or excessive specialty tests and services. I write this with full acknowledgement that I myself am trying to teach myself 'the flow of money' to make up for the very little I learned as a trainee.

2 comments:

Alex Smith said...

Great post Helen. I think I'm in academics in part because I am afraid of the business side of medicine. As physicians, we enter into a fiduciary relationship with our patients, a fancy way of saying patients trust in us to place their interests above ours. The financial side of medicine is a slimy slope that leads self-serving doctors, erodes patient confidence, and is responsible in part for the rising costs of health care. Atul Gawande wrote eloquently about this in the New Yorker, and UCSF's own Dr. Bob Wachter on his blog commented on the issue:

http://community.the-hospitalist.org/blogs/wachters_world/archive/2009/06/05/gawande-nails-it-on-healthcare-costs.aspx

As Bob notes, the Office of Managment and Budget director Peter Orzag commented on this issue here:

http://www.whitehouse.gov/omb/blog/09/06/04/McAllenRedux/

The New York Times reported that President Obama made Atul Gawande's article required reading for his white house staff...

ken covinsky said...

Helen---thanks for linking us to that interesting NY Times article. I think it expresses a lot of the ambivalence many of us feel about the "business" of medicine.

It seems clear that if one wants to be a change agent in medicine, one really needs to understand how the business aspects work. The no money no mission principle seems to apply to just about everything, and we really need to develop more knowledge of how dollars flow.

I think one of the problems though, is that to the extent that medicine is a business, it is a very badly run business. Our system is incredibly inefficient, expensive, and unjust in its failure to deliver needed services to a huge segment of our population.

I think physicians who are dedicated to the care of underserved frail elders, such as you and your colleagues at Over 60, can be better empowered to serve your population if your dedication is combined with business savvy.

I think the problem the NY Times piece gets at is when the business part trumps the professionalism part. When $$s become primary and patients become secondary, medicine starts to feel more like a trade than a profession and a calling.