By Alex Merto, NY Times, to illustrate this article below.
By Paul Goldfinger, MD, FACC. (I wrote this piece in 2014 but it could have been written yesterday.)
Since 2014, the damage being done to quality care is becoming much more clear. By now most of you have gotten a taste of what the ACA has wrought. Yet there has been no discernible public outcry, but just speak privately to nurses, doctors and patients.
I do realize that as long as patients have insurance, they will put up with almost anything.
When someone I know was recently (2018) in a horrible car crash and wound up at Jersey Shore hospital with serious injuries, he was tended to by a “trauma team” but no physician saw him until the next day; and mistakes were made.
Here is the 2014 post:
In our Blogfinger series about the Affordable Care Act, I said that practice guidelines without flexibility for physicians to make individual decisions for patients would compromise quality. But since the details of how medicine would be practiced under the ACA was not available, I predicted that once care was actually provided under the new system, we would begin to see the worrisome truth.
Now, in an opinion piece published yesterday (2014) in the New York Times*, and written by two doctors from the Harvard Medical School faculty, we find out that “financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks, and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctors decisions.”
This quote (above) is from the article written by Drs. Pamela Hartzband and Jerome Groopman, both well known authors on the subject of what’s right in the care of patients.
When I was learning to become a competent practicing physician, I was taught that patients should be viewed as individuals. In fact, it is those individual differences that make the practice of medicine so fascinating and demanding. For example, consider hypertension (high blood pressure.) Between the different causes, complicating factors, various manifestations, and the myriad of drug combinations and interactions, each patient poses a unique challenge.
High blood pressure, a extremely common condition, cannot possibly be reduced to guidelines that are suitable for the group as a whole. Doctors must be able to treat each case individually, and, their professionalism must be trusted to make the right decisions. What is the point of spending about 10 years of one’s life becoming a doctor if bureaucrats turn the profession into a mindless field governed by mandatory robotic rules, financial priorities, and staffed by unsupervised non-physicians?
It is now becoming apparent that the new health plan is providing regulations and incentives that compromise the doctor-patient relationship. Physicians have a moral imperative to place the patient’s best interests first. That is one of the prime values for the practice of medicine. But to adhere to that imperative is becoming more difficult.
The cat is now out of the bag. The public must pay heed to what their doctors are saying about this situation. My own doctors, almost uniformly, say to me, “You got out just in time.” Many have become employees of large corporations.
According to Drs. Groopman and Hartzband, “The power now belongs, not to physicians, but to insurers and regulators that control payment” In other words, the bottom line is becoming the top line.
To help patients understand what conflicts of interest may be occurring in their care, the authors say, “We propose a …..public website to reveal the hidden coercive forces that may specify treatments and limit choices through pressures on the doctor.”
The Times opinion piece concludes by saying, “Medical care is not just another marketplace commodity. Physicians should never have an incentive to override the best interest of their patients.”
Thanks for sharing. It is frustrating when doctors have less and less control over medical care.
A.C. mentions the movement by insurers to manage care based on population outcomes. This is a VERY dangerous and BAD trend.
As illustration, consider that Avastin, an expensive cancer drug, may only improve the life expectancy of the full population of patients who use it by an average of 5 months. However, about 15 percent of patients benefit greatly and live >5 years — some for many years. If you only look at the population average, you’d conclude that it’s not worth it to use the drug. But if your wife or father or daughter were part of the 15% who live much longer than the average, you’d be doing them a huge disservice not to allow them these addition years of life. Giving them Avastin would be maximizing individual patient outcomes — also known as the system of care we had in the US until the insurers (in league with the ACA and those in Congress who actively supported the destruction of the US healthcare system) decided that individual care doesn’t matter any more.
Curmudgeon: Excellent comment. Thank you.
The health insurance companies take their marching orders from the ACA managers. Only those insurance companies that agreed to the ACA design of how health care is “managed’ were allowed to participate and to get a piece of the profit pie. Much of what is found in those thousands of pages has to do with reducing costs, and that’s where the bullying of doctors is spelled out, and interfering with the doctor patient relationship will mean a decline in quality care.
The insurance companies not only benefit from the subsidies which are received by about 80% of those who sign up with healthcare.gov, but they have been promised relief if they should lose money playing the game with rules written in Washington.
It is a scam, and the patient is not being treated as the top priority, and all of you out there will experience the quality and cost mess starting now and getting worse as time goes on and as bailouts for insurance companies get eliminated in 2017.
As far as “blame..on the medical profession” you are right about that. Throughout my career I was dismayed by the greed, sloppiness,and distorted priorities practiced by a minority in my profession.
The medical profession could be a sleeping giant that could help deal with fraud, waste and abuse. We didn’t need a new system to get with the program on this huge problem. —Paul
I read the Times op-ed piece too, and was not surprised. First, practice guidelines are not intended to be used as a weapon. It’s a sad state of affairs that this is going on, especially if the practice is widespread. The authors are well-known critics of the industry, and one might even call them “Healthniks” (aka do-gooders). But I think the trend toward population norms rather than individual patient assessment in setting standards for treatment is probably very real.
Second, I think it is unfair to blame Obamacare for this. It is the insurance industry that makes these decisions. I’m sure the temptation to run things by the numbers must be overwhelming in the age of big data, where extensive analysis can be performed on massive databases of health encounters. Expect more of this.
Lastly, the insurance industry does have some responsibility for promoting cost-effective care. It’s tough to measure outcomes in health care, and they need to get better at it for guidelines to be effective.
I suggest reading the recently published Doctored: The Disillusionment of an American Physician by Sandeep Jauhar, MD, PhD. He is an academic cardiologist, and is forced to moonlight in private practice in order to make ends meet. The book provides a balanced view that places a little blame everywhere, including on the medical profession. My view – nothing will get better until fee-for-service medicine goes into the dustbin of history.
Physicians rarely strike. And, besides, who would they strike? This problem is political, and the snowball is racing downhill and is huge. –Paul
Time for a physician strike. Headline: “Physicians strike to protect the quality of patient care.”
Jason: This goes back to the 1980’s when Health Maintenance Organizations (private companies) came on the scene to provide health insurance. They tried to dictate to doctors and patients, but both of those groups were on the same page and fought back.
HMO’s mostly vanished then, only to resurface now in the form of an insurance company/hospital corporations/ government monolith/steamroller which is currently burying the medical profession. Doctors have been painted as the bad guys. But reform of the profession’s problems could have been accomplished. The AMA blew it by supporting Obamacare.
My friend, a leader of a well known New Jersey oncology group, is banding together with colleagues from three states to develop enough clout to stay afloat as a private medical business. But the prognosis for them is not very good. Maybe with some reform of the ACA, physicians could regroup, but that won’t happen unless fee-for-service medicine is destroyed. —Paul
From the Government’s/Insurer’s perspective, it’s corrupting for a pharmaceutical company to give the physician a pen or a lunch but it’s OK to take a doctor’s salary/bonus (or dismiss them from the network) if they don’t practice medicine cheaply enough.
My neighbor is an internist and he says that he has been warned several times that he risks being removed from a key insurance network by the insurer unless he becomes more “efficient” in how he practices medicine. Last year, he did not get a performance bonus because he was “off the norms”. They give him “targets” for how often diagnostic tests should be ordered and how often referrals to specialists should occur.
His view is that quality for an individual patient is not in any way a consideration. He tells me he can’t wait until he retires in 5 years. BTW, this insurer is one of the largest in the US.
He says a patient should always ask their physician if the doctor’s recommendation for treatment/follow-up is what he/she truly believes is the best course of action, or if its what the insurance company is dictating.
Looks like it’s time for doctors to stand up for what’s right. Why are they silently compromising their principles?
This is sickening! So if I get a cut on my finger, it won’t be the doctor telling me the size of the bandaid to put on it, assuming he is even allowed to mention this protective device. An outside source will make that decision, if even one is allowed to put on the cut. Does this make sense?