Dr. David Leffell, the former president of the Yale Medical Group, recently wrote an editorial for the WSJ in which he discussed the unintended consequences of the new healthcare law. Specifically, Leffell discusses what the law is doing to change the practice patterns, mindset, and status of American doctors. He also muses about the impact these changes will have on patient care. Read the article here.
As Leffell observes, doctors are now facing an increasingly burdensome set of regulations as they prepare for the onset of ObamaCare in 2014. The signs are clear; Reimbursement will go down for private doctors, overhead will rise, and regulations will multiply. Physicians are looking for any-port-in-the-storm, says Dr. Leffell. Some doctors are quitting or retiring early. Many more are selling their practices to hospitals or large groups to escape having to deal with the new governmental regulations. What this means is that doctors are opting to become employees of a new, massive government-corporate complex as opposed to being independent professionals running their own practices. After decades of encroachment on their professional lives from big insurance and the federal government, doctors are finally waving the white flag.
How might this conversion to doctor-turned-employee change the doctor-patient relationship? First, the doctor will lose his sense of ownership of and responsibility for his patient. This will occur because the doctor will increasingly lose clinical decision making authority. There will be “guidelines” from medical administrators on how patients with specific diseases should be treated; something called “best practices.” What the doctor believes is best for his patient will be replaced by recommendations from a committee of appointed bureaucrats, who will determine what is best for groups of people with similar conditions. As the doctor becomes a follower of algorithms, he will be viewed as just another cog in the machine.
This business of telling doctors how to practice using cost-effective algorithms is nothing new. It proved to be a failure in the 1990s as the HMO movement micromanaged medical care to maximize their profits. Doctors were treated like employees in the HMO model since they signed a contract agreeing to abide by the HMO’s rules. In addition, a not-so-subtle renaming of doctors was used by the HMO executives to diminish the doctors’ status. Doctors were suddenly called “providers.” Of course, it would be irrational for an insurance executive to tell a physician or surgeon what is best for his patient. However, it was perceived as quite reasonable to remind a “provider” that he had already signed a contract, agreeing to limit his care based upon the rules detailed in the HMO contract. And this is exactly what the HMOs did. As we all know, the HMO movement neither improved medical care nor lowered the cost of care.
In the new system, the patient will also be grading doctors on perceived performance, something that Dr. Leffell did not address. The patient will become a customer of the clinic – someone the doctor must satisfy. The patient will be asked to fill out satisfaction surveys to make sure that the doctor is kind, courteous, and respectful and has a nice bedside manner. This process has already begun in hospitals in Tucson. If an employed doctor at the Oro Valley Hospital receives a less than excellent review from a patient, say from a drug addict whom he denied narcotics, this will be noted. The doctor will then be visited by an administrator to discuss the physician’s behavior, since low ratings on patient surveys now results in automatic cuts in reimbursement to the hospital.
When a doctor begins to view himself as an employee, and agrees to be “graded” by those who employee him and those whom he treats, he agrees to accept ‘group-think’. There is no longer a drive for medical excellence based upon professionalism and academic rigor. The goal is to collect a paycheck without upsetting patients or administrators. The goal is to go along to get along. In exchange for his own job security, the doctor relinquishes his professional control and autonomy. He gives up, to a significant degree, his independent clinical decision making.
In all likelihood, this government-corporate model will be even worse than the HMO model of the 1990s, because physicians still owned their own practices and they could always drop an HMO contract. However, to fight your employer in this new system will amount to professional and financial suicide. As employers exert more and more control over their employed doctors, the administrators will ultimately cross the line. Doctors will be forced to band together to have a stronger voice. As Dr. Leffell projects, unionization in this new world will appear quite rational. Leffell states that doctors will soon occupy a service niche like “the chambermaid in Las Vegas or the school teacher in Chicago.”
It’s all about cost control: The doctor who signs on the dotted line and becomes an employee understands that the motives of his new employers are strictly financial. Doctors understand that the hospital administrator’s goals are to control costs and maximize profits. The only way an administrator can control costs is to control physician behavior, by restricting the number of tests and procedures that a doctor can order, along with limiting expensive treatments. Leffell puts it this way:
For cost control to be effective, the professional autonomy and independent clinical judgment of the physician and other providers must in some measure be sacrificed to standardization. This can’t be accomplished by overseeing thousands of doctors in thousands of offices and medical complexes, each conducting its own symphony.
The Magnitude of this Change: This shift in professional identity from the doctor as professional and independent-thinker to employee will have a profound impact on the quality of medicine that is delivered to patients. The unstated agreement that physicians of my generation had with society went something like this: As a doctor, I agree to dedicate my time, effort, and intellectual resources to educate myself and become the best that I can be. I agree to think independently and act as the advocate for my patient. I accept these sacrifices in exchange for my professional independence. I accept the burden of caring for another human being. I will take responsibility for that life and do whatever is humanly possible to fulfill my pledge, often at all hours of the day or night, on weekends and on holidays. In exchange for that sacrifice, and commensurate with the responsibility of that role, I will have the freedom to use my own judgment, make my own decisions and set my own price for my services, based upon the perceived value of my skills.
The new, unspoken physician credo will read something like this: By signing on as an employee of hospital X of Mega-Clinic Y, I agree to follow the rules and regulations of the clinic. I will also follow the algorithms of best practices as determined by a board of appointed bureaucrats and my employer. I agree to suspend my own independent judgment in clinical matters because the system is now too big for me to fight. I understand that some of these algorithms may not be in the best interests of my patient. I also understand that this system may not be in my own best interests. However, I frankly don’t want to work as hard as my predecessors did. I’d like more vacation time. Like other people in society, I’d like to work fewer hours. I, therefore, agree to provide medical services based upon a collective model. Furthermore, if something goes wrong as a result of abdicating my own judgment to the algorithm and its writers, I really can’t be faulted. You see, I am just following the guidelines provided to me by my employer. Furthermore, should there be any serious infringements upon my vacations, my pay or my working conditions, I will address my complaints with my union representative at the United Patient Worker’s Union (the UPW). And finally, please don’t call me after hours.