The Physician's "Squeeze"

As a person outside the medical community, I want to mention a couple of scenarios I've read about that are emerging in this country affecting physicians.  Much of this information is based on a report by Dr. Sandeep Jauhar (author of Intern: A Doctor's Initiation, 2009) in SaturdayEveningPost.com (Jan.-Feb.'15, pgs. 34-38, 78).

Let's start with where the U.S. ranks in life expectancy among developed nations - #45 - according to a report by The Commonwealth Fund, a healthcare research group.

If you live in Miami, Medicare will spend $8414/person/year versus $3341/person/year in Minneapolis. Why?  A large supply of doctors in Miami means more per capita utilization of services and testing, hospitalizations, and intensive care stays.

Doctors in this country are reimbursed for whatever they bill.  They're paid separately by insurers for patient visits.  As long as their patients are in the hospital, doctors can bill and be paid for each visit. In our healthcare system, "if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur."
(SaturdayEveningPost.com, Jan.-Feb., '15, p. 36).

Volume counts.  Fear of lawsuits creates volume in terms of services (some unnecessary) and referrals.  Better-informed patients might be the most potent restraint for over-utilization.

Here's the other side of the coin.  According to Dr. Jauhar, he was under pressure
at Long Island Jewish Medical Center to reduce the length of stay of patients
hospitalized with heart failure.  The shorter the patient's stay, the more the hospital's costs were reduced (associated with less use of hospital resources during a shorter stay).

It's a physician's squeeze.

The result?

Doctors are trying to sell their practices; uncompensated care is growing; admissions and elective procedures (money makers) are declining; and hospitals are cutting costs, staff, and services.

Dr. Jauhar suggests several options:
          - Hire doctors as employees and put them on salary, removing incentives to
            overtest
          - Use bundled payments for packages (an entire hospitalization, for example),
            rather than discrete services
          - Move to an "accountable care organization" in which teams of doctors would
             be responsible (and paid) for patients' clinical outcomes.  Most doctors have
             performed poorly in such situations. (pg. 38)

A recent Time magazine article by Steven Brill  (Jan. 19, 2015) suggests another option:
          - The University of Pittsburgh Medical Center's model (Brill also cites the
            Cleveland Clinic's model, a 75-facility enterprise)
             in which hospitals, doctors, clinics, AND INSURANCE COMPANY would be
             under one roof.  Tight regulations for these conglomerates, mostly through
             use of
             federal anti-trust laws and state regulatory authority, would ensure their
             accountability.  The in-house insurance company
             would have the incentive to control the doctors' and hospitals' costs
             AS WELL AS the means to do so. There would be less incentive to
             inflate costs or overtreat, because the in-house "boss" would get the bill
             through the insurance company.





 
       

My Father's Voice

This guest post is by pharmacist, author of murder mysteries, and friend, Don Weiss. 

My father died on August 8^th, 1982.  I was 30 years old.  The day of his funeral dawned hot and sunny. I was amazed at the number of people who showed up at the cemetery. People whom I knew and people who were perfect strangers. The common denominator, my father had touched these people’s lives in some way. Enough so that they wanted to honor the man they knew in life.

My dad was a member of Tom Brokaw’s “greatest generation.” He served honorably in World War II as a combat field medic, earning a purple heart and a bronze star at the age of 24. 

What I remember about my dad was his sense of humor, his humility, and how he had the ability to make you feel safe when he was around. He was completely dedicated to his sons and his wife, and worked twelve hours a day for as long as I can remember. I can still remember the sound of his car pulling into the driveway and how good that felt.

Going with dad to see the Phillies play at old Connie Mack Stadium and going with him to watch the Eagles play, and the day he took my brother and me to the zoo (to give my mother a break). Trips to the Franklin Institute and the Academy of Natural Sciences and never protesting when my mother would plan a family outing on my dad’s only day off.

When I was a rebellious fifteen year-old, I mouthed off to my father. He smacked me across the face at something faster than the speed of light. It wasn’t a hard slap; it was more for the shock value, but boy did it get my attention. It was the first and last time it happened and with the exception of a brief spanking when I was little, it was the only other time that my father laid a hand on me.

My dad would never come to the table unless he was showered, shaved and dressed and I never saw him get something from the kitchen without asking my mother if he could get her anything.

When I was seventeen and still rebellious, my dad suffered his first of three heart attacks. Two years earlier he was diagnosed with Parkinson’s disease. Both began to rob dad of his vitality and I had to grow up fast to help my mother care for him.

He recovered well enough to go back to work, but he wasn’t the same guy. On the eve of his second heart attack, I was home when it happened. With dad in the backseat, I drove the car to the hospital. Again dad recovered enough to go back to work but three years later at the age of 60, he retired on disability. He cooked meals and did other work around the house as much as his physical condition would allow. On rainy days, he would wait at the bus stop for my mom holding an umbrella. Three years later he succumbed to his third heart attack. Parkinson’s had taken a huge toll on him as well, and he was only a shell of the man that I knew.

My huge regret in life is not spending more time with my dad during those last years. I had moved away seven years earlier and only got to see my folks two or three times a year. I wish that I could have talked with him more. The last words I spoke to him were “Hi dad, how are you?” All he said was “I’m fine; I’ll put your mother on.”

Now that I’m going through my own period of self doubt, I can only guess at what advice father would give me.  All I can hope for is that I’m as good a man.