PROVIDERS

Providers

By

Leonard
Zwelling

         My father was a provider. No, he was
not a physician. He sold plastic. But he provided for my mother, my sister and
me. Eventually my mother returned to teaching school once my sister stopped
coming home for lunch from third grade. My mother then joined my father
as one of our providers. They provided us love and they also provided us
material goods like food, shelter and eventually college tuition and gas money.
My parents, like yours, were my providers.

         I also had a pediatrician and an
allergist as well as a dentist. They were never called providers. Their names all
started the same way. Doctor.

         In today’s Oz-like world of the health
care-industrial complex, provider has a whole new meaning. A provider can be a
doctor, nurse, nurse practitioner, physician’s assistant, mid-level,
chiropractor, massage therapist, yoga instructor or spiritual guide using
crystals to modulate your chi. Some “providers” have the old first name—doctor.
Most do not.

         As a doctor who is not a “provider” any
longer, I would like to cast a vote in favor of reverting to our old
terminology. I understand that political correctness and billing codes demand a
bit of lumping of all those interacting with patients as providers, but I don’t
like it.

         First, I am fine with the inclusion of
all those I listed above and more on the health care team. If someone’s
ailments do not require the input of a physician to ameliorate, no need to call
one in. But the concept of a provider is usually considered one human providing
material things to another. Like your parents. We physicians do a lot more.

         Second, for most of the past 5000 years
of medical practice, we who practice it could
actually provide very little of material use except interpersonal comfort in an
effort to diminish human suffering. And that’s what we provided, at all hours
of the day or night.

It is only in the past hundred years or so that we
“providers” could do a whole lot more than priests for the sick. Lumping a
barber-surgeon with a mid-wife as “providers” may have been true once. It just
doesn’t wash today.

       Third, calling doctors providers is
part of a process of the corporatizing of medicine. Doctors’ offices are likely
to disappear soon as venues of small business having been bought up by huge
conglomerates owned by hospitals or chains of them. What was once a welcoming storefront
for health care has become a trademarked franchise of providers who are salaried employees,
the baristas of bariatrics at the St. Starbucks General Hospital and Co. In the
current fee-for-service environment, where the more you do means the more you
make, the “encounter” (what used to be called an office visit) has become the
unit of business. The greater the number of encounters per unit of time
delivered by a provider on a fixed salary, the more money the health care
enterprise makes. Thus, the bean counters and operations experts overseeing the
corporate health system push the assembly line as hard and as fast as possible.
Physicians who can, rebel and become concierge docs, the Tiffany equivalent for
those who can afford to bypass Zales.

         Fourth, this is likely to change. The
unit of business will soon become the “patient panel”, a group of “covered
lives” for which the health system is paid a “capitated rate”. In this model,
the less you do the more you keep of the lump sum payment given to the health
care enterprise to care for the covered lives. How and when we convert from the
fee for service model to the capitated model will largely be determined by the
great leveler—money, who is making it and who is apt to keep it.

         Fifth, this is all just a means of shifting the risk of the ever accelerating cost of health care (octogenarians and MRIs cost
money and neither were common 50 years ago when Medicare was implemented) from
the insurers to—you guessed it—the providers.

         This is health care economics 101 for
those of you still paying attention. I don’t like it one bit, but I understand
it. It’s our own fault. We got greedy. We over worked the trainees so that they
were sleep-deprived, made errors and now legislation limits their work hours.
Those training in medicine now are used to doing shift work and hand-offs,
something I never heard of when I trained. They seek work-life balance. (Something else I never heard of as a Duke intern). They
seek shorter hours. They may even be satisfied making less money. Regardless,
medicine has changed and it ain’t goin’ back.

         Perhaps we have become “providers” not
doctors. If so, it’s our own doing. But that means we can change it. We need to
determine how we will practice. We need to determine what good medicine is and
“provide” it at a reasonable cost that does not bankrupt the country or its
citizens. And we need to decide that while we welcome all of those who extend
the reach of good quality care to those in need, only a doctor can do what doctors
do.

         And what doctors do was best summed up
for me by my first psychiatrist (yes, I have had several), Dr. Belinda
Straight. She said to me once when I wondered why what she did for me required
medical training:

         “Doctors bring people into this world
and they help them out. They can handle most of what happens in between”.

         And she meant doctors, not providers.