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Money Matters

March 31, 2015

I have been blogging now for about three years, posting once or twice a week and accumulating 240 posts.  I have my little flock of loyal readers and have managed to contribute a few drops in the ocean of the health care policy debate.  But just this month two pieces made some bigger waves, one ending up briefly fluttering about Twitter, the other offered up to the vast and lawless hordes of Reddit.

I doubt that my wisdom, erudition, literary skill, or ability to mix metaphors made these two posts so interesting to so many people.  The subject matter has hit a nerve.  The first post was about how we use and misuse numbers in medicine, and the second made the case that patients are not customers in the retail sense.

The opinions in both cases were pretty much split between people who agreed with me wholeheartedly and those who thought me the most misguided idiot doctor ever to approach a keyboard. Why these subjects?  Why are issues of buying, selling, ratings and statistics in health care so polarizing?  In general commerce whole industries have grown up around the insatiable need for ratings and deals.  People buy stuff on Amazon based on how many stars it has and how big the discount is.  Why is medicine different?

Maybe it is not different.  There are plenty of people who think healthcare should be cast into the competitive marketplace and allowed to sink or swim based on quality indicators and pricing.  Doctor rating websites and magazine hospital rankings provide plenty of opinions and statistics about a vast array of measurements of quality.  Recent pushes towards pricing transparency would allow direct comparisons on the price of procedures, tests, and devices.  A healthcare consumer can theoretically pick a doctor based on a star rating and haggle him or her down on the price of a knee replacement or echocardiogram.  But is that what we want?  To approach our health needs like buying a car or shopping for appliances?

Say you decide to buy a new dishwasher.  First you have to determine that you need a new one, that is, you have to diagnose your problem – “sick dishwasher, terminal condition”.  So you go online to Amazon or Consumer Reports to see which dishwashers get the best ratings.  You notice that the consumer reviews are all over the place.  People either love or hate any given model.  In fact, there are very few middle-of-the-road opinions.  You decide to buy the one with the highest star rating without really knowing or caring that the rating is just a statistical result of positives vs. negatives from consumers who may or may not be anything like you.  You decide to go to Best Buy or Sears to buy the dishwasher you’ve chosen.  The salesperson you deal with wants you to buy a more expensive unit.  The salesperson doesn’t care if you can’t afford it, or if your house is too small, or if the unit is really the best one for your situation, or whether you really need a new dishwasher in the first place.  His job is to get the most money out of you.  Your job is to get the best deal out of him.  Neither of you is at all concerned about the best interests of the other.  Neither of you is looking for a human relationship.  The only thing between you is money.
And that is where the polarization comes from.  Money.  A wise man once said (OK, the best man at my wedding, but he is super wise): all marital conflict is about money.  All commerce is about the money, and since health care is a commodity, bought and sold on a marginally open market, health care is all about the money.  The relationship between doctor and patient has become all about the money as well.  The minute a patient walks into the doctor’s office money is on the table in the form of a co-pay and a request for health insurance information. Resentment around doctor’s salaries blinds people to the administrators and pharmaceutical companies who are pulling in many magnitudes more than your average primary care doctor.  High profile stories of doctors with financial ties to various organizations erodes trust.

Many people don’t realize it, but medical students are taught virtually nothing about money.  It never comes up.  Students are too busy learning how to take care of people, the professionalism and ethics surrounding their chosen field, and how to pass all three parts of the US Medical Licensing Examination.  Most graduating doctors know very little about billing and virtually nothing about cost.  You know what graduates know a lot about that sort of thing?  Business school grads.

Money comes between husbands and wives, doctors and patients, buyers and sellers.  Anything that comes between the doctor and the patient sitting in front of him or her separates two human beings and disrupts the relationship upon which we build trust in each other.


From → Healthcare

One Comment
  1. Darrell permalink

    With respect, I think some of your controversy may arise from the basis of judgment.

    There are two issues here:

    1.Should physicians (and perhaps other professionals in a position of trust and expertise) be judged/rated/graded on the basis of: (a) their cost/fees/charges and/or (b) the opinions of others expressed in reviews or grades?

    That’s a very specific question.

    2. A more general question is: Should physicians (and others as above) ever be judged at all? On any basis? Whether that’s cost or opinions?

    That’s much more general.

    I could argue against number one very easily. I simply do not believe that there’s a correlation between posted fee schedules and quality nor do I believe that reviews and grades are always credible.

    On the other hand, I don’t think there is really an adversarial relationship between quality-of-care and cost-of-care. I think that QUALITY care is COST-EFFECTIVE care, for lots of reasons. Such as not having to do things over, such as arriving at diagnoses quickly and efficiently by the shortest route possible. I am not insulted by a two minute OV if the physician is experienced and can determine the problem and arrive at the solution in those two minutes. Why hang around? I’ll get back to work and she can get on down to exam room 7.

    As you know, CPT-4 has a dozen or so E&M (OV) codes and they’re mostly based on “face-time” between physician & patient. But what is one physician is a poor diagnostician and the other has seen that condition presented hundreds of times or more? In one case, the 15-30 minute visit is not enough and in the other would be a waste of time.

    After all, surgical procedures are not reimbursed on the basis of time spent (well, not exactly anyway), and thank God for that.

    But what about that general question #2 above? Can we judge at all?

    What about the cardiologist who routinely places stents where there are no blockages? Or the dermatologist who performs Moh’s procedures when the lab came back negative for malignancy? What about the surgeon with a high fatality rate on cases on low or moderate severity? What about the specialist with a high infection and readmit rate?

    May we not judge?

    More recently, may we not express concern about a hospital with a spate of infections traceable to inadequately cleaned and sterilized endoscopes?

    I had an upper & lower endoscopy last month at a hospital with dedicated endoscopic suites and trained support teams backing up a gastroenterologist with good credentials, both medical school, residency and fellowship. But I joked with them before the procedure and said something like “Since you’re doing both and upper and lower and since I know you folks are trying to control costs, if you’re using the same endoscope for both, would you mind doing the upper first?”

    They’d heard it before.

    So, should judgment be based on money and non-expert opinion? Probably not.

    But should patients be permitted to judge? To choose between alternatives? To question?

    I suspect that most of us will regardless. It’s very human.

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