- As I explained to my medical student this morning that I was ordering an ultrasound on a patient first because the insurance company wouldn’t authorize a CT scan without it, it occurred to me that medicine derailed from the its true purpose. Shortly later, I found myself again pointing out why I was prescribing a certain medicine rather than the one I wanted because it was not on the formulary of the patient’s insurance company. True, healthcare costs are out of control and all parties in the system need to help rein in the runaway medical economics. Most of the time, a brand name can be replaced with a generic, for example, but many other times, an alternative drug is not actually equivalent and not the best one for the patient.
How has medicine jumped the shark? (Jumping the Shark= The beginning of the end. Something is said to have “jumped the shark” when it has reached its peak and begun a downhill slide to mediocrity or oblivion as per The Urban Dictionary).
- Medical decisions are often driven by insurance company determinations. While as a doctor I may think an MRI is medically necessary for my patient, most patients will not be able to afford one unless their healthcare coverage pays for it. When the insurance company comes back and denies coverage, I need to find alternative diagnostic tests or treatments for my patients. Sometimes they just serve as an added layer of bureaucracy that we are forced to surrender to. But, there are other times when a patient’s life can be put into danger.
- Insurance coverage has become more complex to the point of being convoluted. Patients are now footing the cost of the premiums themselves. And then when they need medical care, they are hit with obscenely high deductibles, It is not just confusing for patients but for medical staffs as well. One insurance company can have twenty different plans. If you are fortunate enough to get everything your insurance covers and doesn’t, good for you. But, for the rest of us, we can expect hold times of hours and getting three different answers for our troubles.
- Medical data is more valuable than the patients it belongs to. We’ve seen all the talk of EHRs and their benefits and disadvantages. While doctors have always kept notes, it was to have a record to refer back to when a patient came for medical care. Now, it is a billing capturing tool. Insurance companies use that data for much more than just determining whether a patient is receiving good care. Being on the frontlines, it very often seems like a game they designed to more easily deny claims. While a patient is holding their belly in pain, I now have to spend more time figuring out the right ICD-10 code to the highest degree of specificity so I can have a better advantage in the prior-authorization game. It takes much more time to ferret out the “right” code than it does to develop the treatment plan and consider all the diagnostic possibilities.
- Hospitals are big businesses. I’m sure they’ve always been run as a big business. But now, there are discharge planners who help decide the best time to get the patient out of the hospital before their insurance company stops paying. During my training, we sent the patient home when they were medically well enough to go home. And guess what if they are now discharged home too early these days? If they come back within 24 hours it is considered a “never-event” and the hospital will not get paid, even if the insurance company determined they would not pay for any more days because it was not medically necessary for the patients to stay in the hospital.
- Regulations have evolved to monstrous proportions. There are so many now that a discussion of them all would require a whole book. But one example is HIPAA, It is important to respect patients’ privacy at all costs. But, many people implement them while not understanding them. I recently was asked to have a consent to release test results that I had ordered. Clearly, HIPAA does not require the treating physician to get permission to get the results of the tests they need to decide how to treat patients. But, some receptionist somewhere understood this to be a requirement under HIPAA.
So, if you ask me if medical practice has jumped the shark, my answer is a resounding yes. With patients living longer and with more complex diseases, medical practice should be about optimizing their clinical outcomes and allowing doctors to do the things that need to be done to give patients the best cures. Industry CEOs and politicians are not the best ones to determine how the healthcare system should run to achieve this: patients and doctors are.
Copyright secured by Digiprove © 2018 Linda Girgis, MD, FAAFP
We are our own worst enemies. All of us sacrificed through the years of school and training, and we don’t want to sacrifice anymore. So we stood by, grumbled and groused as our profession was stolen from us by government bean counters, insurance companies and bureaucrats expert in intended and unintended consequences. We were more concerned about patient care, paying off our education debts, paying a mortgage and raising our children. And our common enemy knew that. Until and unless we stand up as a group and do the right thing, we will continue to slide into oblivion.
hmmmm, let’s see…take $$ from the top 1% and give it to the government…..hmmmm, what part of that doesn’t seem logical? Haven’t figured what that one, not two, things the government does well….not even military. sorry, must disagree with the re-distribution argument.
I would disagree with “Stop giving tax cuts to very rich people and there will be plenty of money.”
I’ve seen what looked like well-backed-up data that even if ALL income was confiscated from the top 1%, it would run the economy for only a few weeks. And of course if that were attempted, the top 1% would either quit working harder, or leave the country – we’ve seen them migrate at both state and national levels before for such reasons. So no – we wouldn’t have “plenty of money” if we increased income taxes on the wealthy (they already pay most of the income taxes anyway).
I would also disagree with “Price controls, which is how it works in other countries,”
Price controls consistently have two effects – they increase the price of mediocre products and services, and they decrease the quality of the formerly more expensive products and services. Imagine a $10 ‘meal voucher’ because some bureaucrat decides restaurants can serve a decent meal for that price, so you go to White Castle – they made decent money on $5.00, maybe $1.00 profit after expenses – now they will make $6.00, without ANY motivation to improve their product. Now go to Bonefish Grill and give them the $10 voucher – see if your ‘swordfish’ dinner doesn’t taste more like dumpster-cat.
There is a reason ECONOMISTS do economics, and physicians do medicine. Our great intellect doesn’t anoint us with magical abilities to formulate sound public policy just because it peripherally involves ‘health care’.
Largely true. Insurance companies will argue, often with justification, that their decision algorithm is based on “evidence based medicine.” True, however, there is only a very limited number so called, peer review journals that are acceptable to CMS…of course the docs never really know which journals those might be. You mention diagnostic detail….for claim denial…perhaps. However of more importantance is the ability to increase, with accuracy, the patient’s clinical risk, i.e. risk adjustment. In general, for every patient panel of 2000 patients, there is often hundreds of thousands of dollars left on the table….most of which the insurance company can recoup from Medicare. So, us docs on the dark side often work hard to approve what the docs want, often ignoring the “rules.” Sometimes, the requests from the docs are insane as well. The truth, so to speak, is somewhere in the middle.
Unfortunately we’ve identified the enemy…and he is us…to paraphrase
Abdicating our responsibilities in the leadership and management of medicine to organized medicine and the business drones has brought us to this place….It’s our fault. Not sure it can ever be recaptured, for too often “we” fight those of “us” that have tried to regain control of the beast….I’m glad I’m at the end of my career…though miss the good ole days without question. wb
Happy Days was dead before Fonzie jumped the shark, but it gave a great contribution to our lexicon.
As an issue, I consider this horse not only dead, but a decayed one! Simply take a look at the recent supreme court confirmation battles (regardless of your political preferences) and you’d understand the priorities of our policy makers.
As soon as we violated the Hippocratic Oath by allowing someone OTHER than the patient to pay us, the die was cast.
Nothing will solve the problem EXCEPT removing that payment model.
Payments can be buffered two ways:
1) by time (for the patient who doesn’t have enough money to treat their pneumonia/laceration/whatever today). That works for ‘routine’ or minor expenses, akin to buying a new refrigerator by a payment plan. We don’t need ‘third party’ payments for that – any bank or credit card can buffer payments by time, and even poor patients can access that kind of thing, other than true ‘poverty’ cases, which can and should access charitable funding mechanisms.
2) by person (for the rare, unexpected, costly items that only a small segment of the population needs). Yes, there is a need for some form of risk-pooling, and ‘insurance’ can do that. STILL however we don’t need to take payments directly from the insurance company. Payment plans and buffering-by-time can start the reimbursement process until the insurance processes the claim for emergencies, and by making the patient be in the loop directly for non-emergency situations, the market forces will FINALLY get back to promoting the highest quality services for the lowest cost, instead of what we have now, which is often the opposite.
Medicine jumped the shark 30 years ago with RBRVS and RVUs. It’s been downhill since then. I’m looking forward to a quick and painless death rather than having to spend my golden years fighting with an idiotic system.
Hmmm….Whomever Congress “sold out to” will be largely determined by your political leanings, but, I have to say, we did this to ourselves. We let insurance companies in, we let patients think health care is free, we let costs inflate beyond the range of inflation. Decades ago, my grandfather charged $2 a visit. He never took health insurance. He drove Pontiacs instead of Mercedes. He made his money in real estate. I hate to break the news to everyone, but patients do not think we deserve $300K a year. If the market was really allowed in to our industry, drug prices, hospitalizations costs, and our salaries would take a huge hit. About 40 years ago, the average internist made $80K. That is probably what we would make now if the market determined our income.
If you think there’s a doctor shortage now, wait until that becomes the salary scale.
Also, 80k 40 years ago would be worth about $317,000 now, using CPI as the inflation adjustment.
80k? Purchasing parity has dropped by 90 percent over forty years. That’s why cataract surgery used to be called Cadillac surgery. Doctors are making much less today than forty years ago. My old boss used to play three hours of golf midday every weekday that it was not raining. My generation can’t even afford the membership. This is not to whine but to clarify.
80k 40 years ago is just shy of 324k in 2018 after adjusting for inflation
Patient’s don’t mind if you make $300K a year if you are a decent human being and don’t flaunt it. 50 years ago physicians were pillars of the community. They were visible outside the office. They were on school boards, appeared at community functions and often volunteered their time. I worked in a small community 35 years ago; we got together one Saturday afternoon and did mass school physicals for nothing. It cost us a couple of hours of our time.
My family doc had the big-ass Buick Riviera with the boat tail rear end. No one thought any less of him.
As an aside, sort of, the expression “jumped the shark” refers to the show “Happy Days,” when Fonzie jumped the shark while water skiing. The show never recovered from after that episode and was cancelled. And yes, I agree that what we knew as Medicine may not ever recover. We’ll only reminisce about the good old happy days when watching reruns of Marcus Welby, MD.
https://en.m.wikipedia.org/wiki/Jumping_the_shark
Excellent analysis, and so true. We all know this though, but we also know that we need close to 100% physician cooperation to make the needed ‘Break.’ The trouble lies that some physicians have managed to game the current system and it benefits them so much financially that they would not participate in a complete, I mean complete, overhaul. They have divided us, and now they have conquered. Pretty soon any individual physician who goes alone will be met with some legal restraint that prevents his/her practice to exist. You won’t be able to bill; you won’t be able to prescribe; you won’t be allowed on staff. We can complain all we want but we need some type of god to lead us, ALL of us, in the direction that we know is not only better for our patients, but also cost effective and logical.
I discovered this long ago. We all sacrificed a great deal on our way to this profession so we don’t like the idea of additional sacrifice. But until we just say “No”, we and our patients will continue to circle down the drain and medicine will be no more.
Great post Linda, even though it is a bit late to the game. However, I must disagree with your conclusion that patients and doctors are the best ones to determine how to fix the system. Patients are largely clueless – they can tell you if the food in the hospital is good or not, or if their doctors office treated them kindly and promptly, but they cannot tell the difference between good and lousy care. Doctors should know, but look at what they have done – look at the AMA, which fought Medicare and Medicaid tooth and nail, calling it socialized medicine and demonizing it – they were also complicit in deep-sixing the Clinton’s abortive attempt to reform healthcare. Politicians, of course, are simply prostitutes in 3-piece suits, and that goes with both males and females. They have their hands out and are more than happy to do the bidding of whomever buys them lunch or takes them on a junket. The current administration is on the verge of destroying everything that makes our country good. Anyway, enough sermonizing. Good job on your post. My advice: support a public option as the first step to regaining our profession – get rid of Medicaid, and offer Medicare for all, with the premiums on a sliding scale basis. If it doesnt work, fine. My guess is that it will work just fine – then sit back and watch what happens to the insurance companies and their huge denial programs.
Keep up the good work!
Medicare is bankrupt now; the future obligations are anywhere from 15 Trillion to 40 Trillion. What do you think will happen if it is expanded? The government can build roads (most of the time) and build weapons. It isn’t much good at anything else.
Medicare isn’t bankrupt. You fund medicare for everyone the same way other countries do it.
1). Everyone pays into the system. Stop giving tax cuts to very rich people and there will be plenty of money.
2) Insurance companies lose their clout; in France they sell supplemental policies similar to Medigap policies.
3) Price controls, which is how it works in other countries, so that $94,000 HepC drug here goes for $900 like it does in India.
4). We got money to build weapons we don’t need. Reallocate the money.
I’m nearing retirement. If I was starting out, I’d say, fine, I’ll work for less money. In exchange, I get free medical school, a call schedule and patient load that isn’t going to kill me and you get the plaintiffs’ attorneys off my ass. (I’m an OB/GYN).
What an accurate description of medicine!
Thanks!
Dr Linda, Terrific post and best terms for today’s “upside-down” or topsy-turvy medical care in the USA (my words for my aghast patients). “Jumped the shark” says it best. Dear patient, you are alive now through this bureaucratic hit only to be exsanguinated in short order as the shark returns for the kill.
Thanks for your comment!
Dr. Linda
The organizations that are supposed to represent us abdicated their obligations a long time ago, allowing bureaucrats, beancounters and politicians to control Medicine.
It is easy enough to snarl at insurance companies, but, why is an MRI several thousand dollars? ER visits can be tens of thousands? One biological injection for RA several thousand dollars? The amounts are decided by non medical businessmen who have no ethical compunction or licensing boards. They decide “that is what the market will bear.”
Medicine was never supposed to be run according to “what the market will bear.”
You get what you elect.
Hello Dr. Linda:
I hope you are recovering well from your recent injury.
I fully agree with your diagnosis that medicine has jumped the shark.
The shark was jumped when the buffoons we elected in Washington sided with BIG business whereby taking the doctor and his/her patient out of the equation and allowing insurance companies to dictate what’s best for the patient.
Until the public really opens their eyes & sees the damage their elected officials are doing to THEIR healthcare this will not change.
This country spends close to $4,000,000,000,000.00 (that’s trillion), annually on healthcare and what do they get for it? Insurance companies (not doctors), saying whether someone will get the treatment they need to live.
The healthcare industry routinely trades peoples lives for the almighty dollar.
What the buffoons in congress and big business think is best for us is to keep lining their pockets while draining ours.
It’s time for the people to take back healthcare & put people in charge that are people first business second.
Our elected buffoons need to be replaced by people who are willing to do the right thing and enact stronger laws to protect the dignity and privacy of patients while at the same time, reign in costs, cut waste, and make the doctor/patient relationship top priority.
We have some of the brightest minds in the world right here in this country.
You can’t tell me that working together guided by these principals we cannot rebuild a world class healthcare system that everyone would be proud of.
Use the principals of Do No Harm and CPR.
Choice
Privacy
Respect
Do No Harm.
You can’t have one without the other & build a world class healthcare system.
Regards,
Raffie
Thanks and much better!
Yes, I agree. Politicians have largely ruined healthcare for their own agendas. The public needs to to fight back.
Dr. Linda