the modern robber barons…

Posted on Thursday 27 June 2013

My neighbor’s wife called late morning. She had a developed a severe right-flank intercostal pain that felt like a knife. It sounded like Shingles, but there was no rash. I gave her two left-over pain pills from her last dental surgery, and planned a later visit to see the rash that I expected to come soon and start Zovrax [an antiviral]. The pills helped, but when I showed up later, they were gone. I guess she got worried. I found her in the ER where she’d had a blood count, urinalysis, Chest X-Ray, and an EKG but hadn’t seen a doctor. In a while, he came in and when she rolled over, there was the Shingles rash. She went home with some pain pills and Zovrax.
A friend called on the way home from an overnight speaking engagement. The day before, he’d developed right sided lower abdominal pain, nausea, and anorexia. Later he had fever and vomited and the pain became diffuse, then disappeared. He struggled through his talk, went to the motel and slept for ten hours. Malaise and fever persisted and he headed home. I thought he’d ruptured an appendix and told him to head straight for the Emergency Room. While all agreed with the diagnosis, he had both a CAT Scan and MRI "to find it" before surgery later that night. He had a ruptured appendix.
They called late at night. Their son, a binge drinker, had called after a ten day bender and was "soused," begging for a drink. He was indeed a mess, but his vital signs were stable and he wasn’t dehydrated. I sent his Dad to an all night pharmacy for Librium which settled him down and he was fine in a day or two. Later I learned that there had been a previous episode 6 months before. They took him to the Emergency Room and left with a $10,000.00 bill.
A neighbor called with acute right-sided back pain radiating to the groin. When I got there she was writhing in pain and said, "I think it’s a kidney stone!." She had percussion tenderness over the right kidney. She’d never passed a stone, but they’d been seen on a contrast X-Ray previously when she had a kidney infection. Off to the medicine cabinet for the left-over pain pills. She’s a single woman and I was leaving for a trip early the next morning so off we went to the Emergency Room. After she was admitted there and another friend came, I went home to finish packing. When I came back, her urine had blood in it as expected. She had an IV, chest X-Ray, an abdominal X-Ray, lab work, a CAT Scan, and was scheduled for a contrast X-Ray [IVP] if they didn’t see the stone on the CAT Scan. Meanwhile she went to the bathroom and passed the stone. Cost? $7,700.00…
My 79  y/o friend has had periodic "dizzy spells" for several years, increasing in intensity. He’d seen every kind of doctor in the book in Atlanta.. Although he’d had every test possible, was never hospitalized. The cause wasn’t apparent. After a severe and persistent bout, I was determined to get him hospitalized and had his Internist arrange for a Neurologist the meet us at an Atlanta hospital. But that was not to be, because we couldn’t get him to my Jeep – too dizzy – so we called an ambulance which took him to the local hospital where he had a blood count, X-Ray, CAT Scan, and a particularly rude ER Doctor. By the time that was over, he had zero interest in heading to Atlanta. A week or so later, his wife drove him four hours north where he was admitted to Vanderbilt Hospital and had a thorough work up, was transferred to a research unit, and they made a definitive diagnosis [Primary Dysautonomia].
There are more such stories, but that’s enough to make the point. If it’s not apparent, most of those tests were unnecessary. Expensive tests before seeing the doctor? CAT Scans and MRIs galore in an ER with no diagnostic or treatment goal? It’s fee churning, and it happens every single time I get near that ER. I wrote yesterday: "If you’re an old retired doctor in a community, the phone rings a lot and you end up going to the Emergency Room with a lot of people. I don’t like what I see there." This is what I was talking about. So today, I run into this post on Dr. Poses’ blog, Healthcare Renewal. I’ve only included the beginning and end of this important article. It’s the "why" of the "what" I posted above, and he suggests the only solution:
Healthcare Renewal
by Dr. Roy Poses
June 26, 2013

Evidence has been seeping into public view about the extent physicians who sign up to take care of patients as corporate employees give up their professionalism.

Shut Up…

In April, 2013, Medscape published an article whose striking title was "Can You Speak Out Without Getting Fired or Being Labeled a Troublemaker?"  The answer was basically "no."
    Physicians often see problems at their workplaces relating to patient quality of care, financial practices, mistreatment of staff, and other issues. But as more doctors take jobs as employees of hospitals, medical groups, and other large organizations, they increasingly face the same dilemmas as millions of other working stiffs. When they come across actions or policies that they don’t think are right, they have to decide whether it’s worth it to speak out and get labeled as a troublemaker — or perhaps even get fired.

    Across the country, a growing number of physicians are indeed losing their jobs — and often their hospital staff privileges — after protesting employment conditions. Such complaints may involve patient quality-of-care problems, short staffing, misallocation of funds, improper financial incentives, fraud and abuse, discrimination, overuse or withholding of medical services, or other misconduct, say organized medical groups, employment attorneys, and physician recruiters.

The Moral of the Story…

We have previously discussed various aspects of the travails of the brave new world of the corporate physician.  Physicians and other health professionals who sign on as full-time employees of large corporate entities have to realize that they are now beholden to managers and executives who may be hostile to their professional values, and who are subject to perverse incentives that support such hostility, including the potential for huge executive compensation.  Physicians seem to be willing to sign contracts that underline their new subservience to their corporate overlords, and likely trap them within confidentiality clauses that make blowing the whistle likely to lead to extreme unpleasantness.

It is disappointing that even medical societies that ostensibly support physicians’ professional values have been afraid to warn against such employment, or do much to help physicians trapped within it. Physicians who go to work for big corporations have to realize that they may be forced to put corporate executives’ vested interests ahead of their patients.  Patients whose physicians work for big corporations must realize that their health care will now be corporate, with all that entails.

As I have said before, we need to challenge the notion that direct health care should ever be provided, or that medicine ought to be practiced by for-profit corporations. I submit that we will not be able to have good quality, accessible health care at an affordable price until we restore physicians as independent, ethical health care professionals, and until we restore small, independent, community responsible, non-profit hospitals as the locus for inpatient care.
These are the modern Robber Barons, the Hospital Corporations who take over small community hospitals like ours and indenture their staff into fee churning at the expense of everyone involved. It’s a scam extraordinaire that needs nationwide atention. It’s painful to watch!
    Bernard Carroll
    June 28, 2013 | 12:36 AM

    I can imagine worse. I can foresee that psychiatric patients presenting to general hospital ERs will receive a fixed battery of screening questionnaires to ‘rule out’ even irrelevant differential diagnoses, then a panel of pharmacogenetic biomarkers so the doctors will know in advance the risk of fast versus slow drug metabolism just in case treatment with one of several drugs is contemplated. All before seeing a doctor, of course.

    After RDoC takes hold then the patient may be assessed on several dimensions of crosscutting pathophysiology even though there is yet no working diagnosis. That’s just the point – RDoC churning preempts diagnosis: just ask NIMH Director Thomas Insel. This churning may involve anything from quantitative EEG recordings to functional MRI scans looking at cortical-subcortical connectivity in various frontal-limbic circuits.

    All of this costs money, of course, and will be codified in Treatment Guidelines. Finally psychiatry will be playing in the same league as other medical specialties. That’s what Insel and APA President Jeffrey Lieberman seem to be planning.

    June 28, 2013 | 10:35 AM

    YIKES! Before that Brave New World arrives, I hope a comet strikes this planet and puts us all out of our misery!

    June 28, 2013 | 4:21 PM

    I think the trouble here is that in our society, the idea of monetizing everything and making as much money as possible is often seen as the highest aim, with few having moral qualms about prioritizing individual wealth over any collective good. It reminds me of a recent David Brooks column in which he wrote about the shift in language use in the past few decades:

    That is to say, over those 48 years, words and phrases like “personalized,” “self,” “standout,” “unique,” “I come first” and “I can do it myself” were used more frequently. Communal words and phrases like “community,” “collective,” “tribe,” “share,” “united,” “band together” and “common good” receded.

    Things are, believe it or not, often worse in other places than they are in America. I have a friend whose cousin in China just gave birth at a private hospital. The doctors there wanted to have her undergo a C-section for no medical reason because they would make twice as much money doing a procedure. When she chose a regular birth instead, they decided that they needed to keep her healthy baby in the hospital for 6 days for observation. I hope nothing like that ever happens in the U.S., but it seems sadly plausible.

    June 28, 2013 | 9:16 PM

    Thank you for posting this. This is easily the largest rent extraction sector in the economy. People are increasingly suspicious of health care providers and that is sadly keeping away people who need treatment.

    June 29, 2013 | 3:00 AM

    Medicine and money are like two drugs that give rise to a whole slew of unintended and harmful side-effects.

    Surely the time is ripe for a new, independent hospital trust, based on traditional practitioner values, designed to maximise patient outcomes rather than corporate profits. You could have a series of well paid, experienced doctors, a pragmatic treatment and testing schedule, and do without of many of the spurious and modern technological innovations, at least for the vast majority of admissions.

    The costs would be dramatically lower, allowing patients to receive good, basic care for a fraction of the cost. Physicians working for such a system could be amply recompensed too, as much of the money that goes into current hospitals goes to a few physicians in senior positions. An insurance company, offering such a product at far below it’s competitors costs, would literally wipe the floor with them.

    I’ve heard that hospitals are setting up in various countries around the US to take of advantage of the poor value provided by US counterparts, but what’s stoping this occurring within the uS itself?

    Any ideas? I’d love to know.

    If you look at some of the figures from hospitals in places like India, where the focus has been on reducing costs, even complex cardiac surgery can be completed with comparable survival rates to those achieved in the US.

    June 29, 2013 | 8:39 PM

    Um, is it me, or just repeats of the premise of how the majority of physicians have either embraced or just denied the role of business in health care.

    Gee, surprise, Faust is now fu—d, except Faust is now the profession of health care. Oh, and from personal experience, truth and responsibility in colleagues is like looking for a cure to cancer or eliminating dementia.

    Not going to find either among colleagues until proven otherwise, folks!

    Taimo Peelo
    July 2, 2013 | 3:30 PM

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