I became interested in medicine in my second year of college at Baylor University. I lived in the old Brooks Hall, which was built with large suites and communal bathrooms, and formerly used as military housing. Six of my suite-mates were pre-med and had doctors for either fathers or mothers. They all spoke of the work their respective parents did, and how much enjoyment treating patients brought them, and that medicine provided a good living and security for the family, and in general prompted respect from the residents in their local communities. I was not doing particularly well in my pre-engineering plan and decided to change my major to pre-med. It turned out I was much better in chemistry and biology than math and physics, so it was a good fit for me. I applied to medical school in my senior year and was accepted.

After graduation from college, I spent four years in medical school, one year as a surgical intern, three years in an orthopedic surgery residency, and a final year in a fellowship for foot and ankle surgery. I was asked to join a premier orthopedic group in Houston, and settled down to practice in Houston in 1979.

I would say the first twelve years of practice were straightforward. People would come to see me with an orthopedic problem; I would diagnose the problem, and treat it accordingly. Sometimes the problem was operative, sometimes not. The staff would send the insurance company a bill, and it would be paid. Back in those days, sometimes the patient would pay the bill personally, and would then file a claim with the insurance for reimbursement, which would be honored and paid.

Something changed for the worse in the late 1980s. Insurance companies decided to “discount” a doctor’s services. In plain talk, that was a decision to empirically reduce the fees. Then came the concept of “pre-approval” of services for patients.  My group was in a situation where we were tied to a medical school and hospital and could not “negotiate” our declining payments. As a result, half of us left and built our own facility to provide convenient and less expensive “one-stop shopping” for the patient, such that we could offer clinic visits, radiological testing including MRI and CT scans, surgical treatments, and hospitalization all under one roof. This new situation also allowed the administrative folk to negotiate contracts with payors to maximize our reimbursement such that we could continue to treat our patients and pay our employees and ourselves.

The late 1980s and 1990s also brought a new enemy: plaintiff’s lawyers. A wave of lawsuits against doctors as had never been seen before or since rocked our world. Malpractice insurance policy costs rose to over $100,000 per year per man. It was chaos until the year 2002 when President George W. Bush initiated tort reform. It seemed a large number of the tort lawyers moved to Louisiana overnight.

Over the next fifteen years, the negotiating process between insurance companies and doctors deteriorated. I can remember at group meetings being presented with the newest insurance company contract at another 5%, 10%, even a 15% reduction in reimbursement. And a discussion would ensue as to whether we would refuse to accept those terms and eliminate that particular insurance company from our provider base. What that would mean is that large numbers of patients who worked for companies we had done business with for years would be eliminated from our rolls and would have to find treatment elsewhere. I can remember patients I had treated in the past coming in to see me for the last time, crying, regretful that they would be unable to see me again because we didn’t accept their insurance any longer, and all because the insurance company would not agree to a reimbursement rate that was even equal to the cost of treating the patient.

The problem has continued to worsen over time. I’ve been out of the business for fifteen years. When I left, some insurance companies had reduced the physician reimbursement down to 60 to 80% of normal fees. If one calculates the doctor’s overhead to be 30 to 40% of collections, you don’t have to be very good at math to see that at some point in time, a doctor can’t pay the overhead, or himself for that matter.

My experience as a physician and surgeon was stellar. I was able to practice medicine for half of my career in a golden age when the doctors and insurance companies worked together to provide care for patients. Unfortunately, an adversarial situation exists now between the two groups, with insurance companies denying treatment for the patient/client and offering markedly reduced reimbursement for the physician. The situation will implode in time. Medical school applications are down, and it’s possible that our best and brightest will no longer find the challenge of today’s medicine worth the sacrifice and expense of four years of high school, four years of college, four years of medical school, and six more years of specialty training.

The trend now is for young graduates, whether they are family practitioners or neurosurgeons, or any medical specialty in between, to be hired by large hospital chains as employees. That situation provides a steady income stream, ample vacation time, continuing medical education, and job security, a valid choice for a young person who, in most situations, has accumulated massive debt in order to follow their dreams into the medical world. That position also has the advantage of having a large hospital chain negotiate contracts for their doctor-employees, a huge benefit in these modern times.

Going to work for a hospital was something my surgeon colleagues nor I would have entertained in the “old days.” We were, for the most part, a fiercely independent group and could not stand to be told what to do by anyone, much fewer hospital administrators and insurance carriers.

Kudos to the new breed of health care provider. We are glad you have survived the rigorous road you took to become what you wanted to be and have stepped up and joined the fray on behalf of patients the world over.

Welcome to the changing of the guard.

John Bishop is a retired orthopedic surgeon. He is the author of The Doc Brady Mystery Series. 

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