Medicine, Inc


Leonard Zwelling

         The practice of medicine has always been characterized by
being a two-person endeavor. One person was the sick one. He or she was usually
called a patient (although they have turned into encounters, units and visits).
The other person was the one trying to help the sick one. He or she was usually
called a doctor (although this has become provider with the advent of physician
extenders, physician assistants and nurse practitioners).

two-person endeavor was essentially based on two principles. The doctor had
knowledge the patient needed to heal and the relationship was a fiduciary one
in which the doctor would put the patient’s well-being above all else, even his
or her own. Many doctors and nurses have died fulfilling these principles in
major infectious epidemics and natural disasters like floods or unnatural ones
like war. Those of us who believe in medicine used to believe that the
two-person model was sacred, never to be violated by another person let alone a

         Welcome to the new world of Medicine, Inc.

         Doctors and other providers are now units of service and
revenue. Patients for whom the units care are simply encounters generating
money for Medicine, Inc. The docs are now on salary with their incomes
determined by a contract rather than the hours they work. The revenue generated
by Medicine, Inc. is not determined by the quality of the care but by the
insurance coverage of the patient. Globally, payer mix, the roster of the
reimbursement sources for the “panel” of patients cared for by Medicine, Inc.,
is far more important than the excellence of the care. In fact, what little
metrics of quality there are may be more box checking (e.g., hand washing and
hospital ID tag reading) and patient satisfaction survey results than the
actual outcomes of any delivered care. Don’t believe me? Go ahead and try to
find out the outcome of coronary by-pass surgeries done at St. Luke’s last year
listed by surgeon, anesthesiologist or nursing supervisor on the recovery
floor.  Consumer Reports can tell you all
about the cell phone you plan to buy but nothing about the team that is going
to open your chest and rearrange the blood supply to your heart.

         This corporatization of medicine is affecting every venue at
which medicine is practiced from small clinics that all wish to grow larger to
academic centers that are expanding across cities and countries to bolster
their encounter numbers rolling over the private practice of medicine as surely
as a steamroller flattens newly poured tar. The private practice of medicine is
ending and that’s too bad.

         The main reason this has happened is money. It is far more
efficient to deliver “care” via a corporate structure with the ability to mass
buy supplies like medicines and IV fluids, foist inventory on suppliers,
negotiate better reimbursement rates and limit pay and other fixed costs using
the corporate model than is possible in a small practice of one or two doctors.
The overhead costs of human resources, claims work, regulatory compliance, and
other back office functions are also easier for a corporation to absorb than is
the case for a small business.

Unlike a law office which
requires only a library, a computer and an assistant or two, medicine’s
complexity in the areas of technology, referrals, billing, coding and delays in
accounts payable and receivable, placed it as low hanging fruit for the
business class to harvest and harvest they have.

         I have no answers to this mess other than to make it all
irrelevant by creating some sort of single payer system in which doctors are
salaried, patients get what they need and no more, and the system emphasizes
health instead of disease. This is unlikely to ever catch on.  There’s no money in it.

         So on this day that commemorates the birth of our nation and
its Declaration of Independence perhaps we delegates of medicine need to spend
a summer in Philadelphia and come up with a better plan. We still have the
knowledge. The patients still need us. We just need to figure out a way to
drive the Red Coats from Blue Cross out of here.

         I don’t suggest a Tea Party. But if we all backed a single
payer system that provided our families with income, shared it with one another
and got back to the bedside where we belong and where our patients need us,
even allowing for a cash or high priced insurance market to permit high rollers
access to high rollees with MDs (concierge medicine is all right by me), we
might be able to put the medical-industrial complex of a million or so
insurance executives, coders, billers, lawyers, administrators and other
assorted non-providers out on the street where they belong.

         Then perhaps Medicine, Inc. can go the way of Bell Telephone
and Kodak.

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