Monthly Archives: January 2012

Renewing the SPIRIT of Healthcare

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Over the last few years much has been written and said about the problems facing physicians within the American Healthcare System. The purpose of this particular post is not simply to further define those problems, but to offer a logical solution. The title of this writing is also the “Mission Statement” of my own practice, and the action being suggested is one I have personally employed.

Throughout the western world, universal healthcare has become a touchstone for the progressive, socialist movement. It is after all, relatively easy to argue that everyone deserves access to medical care when they are sick or injured; it is simply the humane thing for a society to provide. But, once the state defines healthcare as a basic human right, they are then faced with the challenge of allocating adequate resources to ensure that everyone has access.

Proponents of “universal health coverage” argue that there are only two viable choices, either mandate that everyone purchase insurance, as called for under the Patient Protection and Affordable Care Act of 2010, or have a government run single payer system where healthcare is paid for through taxation of the population. But a “one size fits all” healthcare system has proven to be unworkable. Even in mature socialized system such as the National Health Service in Great Britain, a significant private healthcare system has emerged. This is analogous to the rise of private schools in America, despite the fact that public education is available and essentially free to everyone. This is obviously a natural phenomenon based on individual expectations and the will to control one’s own destiny.

Another major challenge to various attempts to manage individual healthcare from the top down is the independent behavior of those who actually provide the care. Government bureaucrats and insurance executives have assumed “providers” can be controlled through financial incentives, corporate directives, or government mandates. What they failed to consider is that physicians will consistently attempt to resist doing or not doing things that are contrary to their training and their professional ethics.

Physicians are by nature inclined to put the interest of individual patients ahead of their own, or those of the payer; a concept that is vital to the establishment and maintenance of a meaningful patient-physician relationship. But in recent years, economic motivations and not so subtle pressures from elements of the “third party payment system” have gradually drawn many physicians away from their most basic obligation, like sailors to a sirens song. Such conflicts have created a loss of practice satisfaction, anger and frustration, and a practice environment where many physicians have opted for an early exit from the profession they spent a lifetime pursuing.

Perhaps the best evidence of this changing paradigm is observed simply by calling a physician’s office to arrange an appointment. The first question you will likely be asked is “What kind of insurance do you have?” Healthcare has become all about payment, yet patients rarely even ask what it costs. The system has insulated patients from the payment process, while at the same time doctors who participate in Medicare and Medicaid, or who work under insurance contracts, have virtually nothing to say about how they are compensated.

So what’s the answer? The only logical solution is for physicians to take the lead by returning to their professional roots. This means independently treating their patients according to their knowledge and training, and then looking to the patient for appropriate payment for those services. The ability to truly serve as the patient’s advocate can only come when the contractual bondage to outside payers is broken. As long as physicians continue to sign contracts with entities other than their patients, their true allegiance will be questioned.

The solution is therefore not an AMA solution, or a legislative solution, or a specialty society solution. It is an individual physician solution, which requires a personal introspective analysis. Such self-examination is certainly difficult and the issues are obviously complex. In the end, each physician must decide for himself or herself whether or not a divided allegiance is being used to “manage” the care they provide.

I’m not so naive as to believe that America’s physicians will suddenly receive a collective epiphany, leading to a mass exodus from the insurance roles. The fact is that most physicians are in one or more business relationships that may prevent them from taking such action. Others will not be willing to risk the loss of their financial security, based on “guaranteed” insurance payment. Thus, for a variety of reasons, truly independent physicians are likely to remain a relatively small minority well into the future. But over time they will differentiate themselves by appealing to those patients who recognize the value and wisdom of controlling their own healthcare decisions.

Some will argue that by opting-out of insurance contracts physicians are actually promoting a two tiered healthcare system. Perhaps that is true, but like it or not some consumers want the opportunity to choose from a group of independent physicians rather than being compelled to accept whomever happens to be “on duty” at the local clinic. Certainly the majority of Americans will continue to accept whatever providers are available through their insurance carrier’s network or government program. But, these two options are indeed complementary in an overarching system which seeks to provide healthcare to everyone according to their own choice.

To meet the expectations of a growing consumer-driven, private healthcare system, independent practitioners must work to re-establish a level of trust that has been undermined in recent years. It is time for a new and more modern independent physician’s pledge; one that considers both the rights of patients and the rights and obligations of physicians. To be relevant, this pledge must address the specific challenges of today’s complex world, while at the same time reaffirm the traditional ethics that made the practice of medicine an honored profession over the centuries.

The Independent Physicians’ Rights and Obligations Pledge outlines a new covenant between physicians and their patients based on “mutual trust, mutual respect and mutual responsibility”. Any physician who is considering breaking the bonds of third party contracts should embrace this pledge as a new contract, entered into directly with each patient whom they are privileged to serve. Each physician should also consider this pledge as their personal commitment to the renewal of their own SPIRIT as they continue to pursue professional excellence.

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The Independent Physician’s Rights and Obligations Pledge

 

As an independent practicing physician I hereby acknowledge my role is central to ensuring quality care for all patients. I further recognize the potentially disruptive nature of outside influences on the patient-physician relationship, including various methods of payment. Through this pledge I hereby reaffirm my unconditional commitment to my patients, my colleagues and my profession, and to maintaining my SPIRIT as a physician.

I pledge, to provide personal healthcare to all those who I am privileged to treat, in accordance with my training and experience with a spirit of Service.

I pledge, to uphold, defend and perpetuate the time-honored ethics of the medical Profession.

I pledge, to conduct my practice with openness, honesty, fairness and personal Integrity.

I pledge, to keep the time-honored patient-physician relationship based on mutual trust, mutual respect and mutual Responsibility.

I pledge, to establish just and appropriate fees for the services I provide, treating all patients fairly and with compassion, free from any third party attempts to influence my professional judgment or Independence.

I pledge to work within the community of physicians to ensure the medical profession remains self-regulating and self-governing with respect to education, training, quality assurance and peer review, according to our time-honored Tradition.

Now, before all who are my witness, I accept and embrace these fundamental rights and obligations freely and without reservation, and declare my willingness to abide by them to the best of my ability.

The Healthcare Bubble

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It appears we live in the age of the “bubble”. The current recession was the result of the collapse of the Housing Market bubble. We know about the Credit bubble in Europe with forecasts of countries defaulting. Then there is the periodic Energy bubble here at home, which surfaces every time there is an increase in Mid-East turmoil. It seems we continually go from one economic bubble to the next, but what about the “Healthcare Bubble”?

Recently my son, who is a college student, sent me an article published in Forbes entitled “The Dumbest Idea In The World: Maximizing Shareholder Value” by Steven Denning. This is an essay on how the American capitalist system is being threatened by the practice of executives manipulating corporate performance expectations on Wall Street, in an effort to maximize the value of their companies’ stock. It is a rather intricate discussion, but the conclusion is that over the last 40 years the focus of CEOs has shifted from their products, customers and employees, to pleasing their shareholders with higher stock prices. This is in large part because top level executive compensation is tied directly to the value of the company’s stock.

As I read through this article I couldn’t help but draw a comparison to what has been going on in the healthcare arena over that same period of time. But, instead of shareholders, the priority parties in healthcare are often referred to as “stakeholders”. They include payers (public and private), hospitals and other facilities, regulatory and certifying entities, pharmaceutical companies, medical device manufacturers, a myriad of management companies and numerous other minor players. Oh wait! I almost forgot, there is another stakeholder group known simply as providers. Each of these entities has contributed in one way or another, and often in combination, to a progressive shift away from what has traditionally been a very personal and individual service, to a “system” where healthcare is now doled out as a commodity, largely to the benefit of the stakeholders.

Jack Welch, the former CEO of General Electric, was once the darling of Wall Street because he was the undisputed king of playing the game of maximizing shareholder value. But after his retirement he apparently saw the light. In a 2009 interview he said, “On the face of it, maximizing shareholder value is the dumbest idea in the world. Shareholder value is a result, not a strategy…” I’d like to paraphrase that statement for healthcare; On the face of it, stakeholders managing individual’s healthcare is the dumbest idea in the world. Stakeholder value is a result, not a strategy.

The movement away from the patient as the center of healthcare has been gradual, but it took a major leap forward with the passage of federal healthcare reform in 2010. The Patient Protection and Affordable Care Act is precisely the opposite of what its name implies. It does little to protect patients, is far from affordable and is more about controlling costs than it is about providing care. The true effect of “Obamacare” is to homogenize the delivery of care, with the various stakeholders lead by thousands of unelected bureaucrats, ultimately determining the who, what, when, where and how healthcare services are provided. Moreover, all this is done under the guise of quality improvement and cost effectiveness. The fact the entire federal government, including Congress, and now countless special interest groups have been exempted from this law should provide ample proof of the undesirable nature of such a system.

While CEOs are, by definition, the ultimate decision makers in America’s corporate world, it is the physician who has traditionally held that role in healthcare, but that is changing rapidly. Over the years America’s physicians, the “Chief Health Officers” for their patients, have allowed themselves to be progressively manipulated by the other stakeholders, who’s strategies and tactics have included various financial incentives, regulatory mandates, credentialing guidelines and the most recent trend, physician employment.

An obvious comparison can be made between the corporate CEO who is compensated based on the value of their company’s stock and a physician whose compensation may be based on the profitability of his or her practices to the hospital or insurance company that employs them. Likewise, if the customer suffers when a company fails to respond to their needs, it is the patient who will suffer when their physician’s incentives are misaligned. To date, the only thing that has stood between the patient and stakeholder mandated rationing of care has been the moral and ethical compass of the physician. Now even that is under constant attack by some stakeholders who view the Hippocratic Oath as an inconvenient or outdated philosophy.

The ultimate impact of shifting incentives and conflicting priorities has been the creation of a practice environment where many established physicians feel trapped. On the one hand they can hold to their traditional values and focus exclusively on their patients’ needs and risk financial ruin, or they can compromise those values and learn to play the stakeholder game. Most are struggling in an attempt to do both, but with little success. Many older physicians are opting out of healthcare altogether, while others are simply focusing their practices on services that are outside mainstream medicine. The supply of young physicians, who are in large measure being trained as “shift-workers”, is insufficient to fill the gap created by early retirements and career changes within the older guard. The result is a growing “Healthcare Bubble” where demand for services will soon outstrip supply.

Not surprisingly, one quick-fix being pushed by various stakeholders is a broad expansion in the scope of practice of various paramedical personnel. There is rarely any mention of the level of competence required to safely remove your appendix or manage your high blood pressure.

Many of my physician colleagues have expressed a defeatist attitude, suggesting that changing the healthcare system is impossible. Again, borrowing from Denning’s article, which quotes Vince Lombardi: “We would accomplish many more things if we did not think of them as impossible.”

Clearly, the first step in getting back to patient centered healthcare is the total repeal of Obamacare. This will only happen if the majority of the population demands it, and that is precisely what the next Presidential election is all about. Should Mr. Obama win another term in the White House, there will be virtually no chance that his version of healthcare reform will ever be repealed. If that happens, the Healthcare Bubble is very likely to burst within just a few years. Healthcare will indeed be “free” to all American’s, but will they be able to find it?

 

 

The opinions expressed herein are my own and do not necessarily reflect or represent the policies or opinions of any medical organization or group.

Check out my web site at www.robertsewellmd.com