A large part of patient care in the modern corporate setting is working within your restrictions. Most corporate health care settings will limit how wide your scope can be, and this often determines how you treat patients. As a family physician working within a huge corporate setting, this oftentimes leads to alternate outcomes, such as referring a patient to another office where a procedure can be done safely or having to be docile towards insurance requirements and administrators. In America, insurance plans dominate the treatment of the primary care patient, so the selection of medications and treatment will often be up to the insurance provider rather than the medical provider. The insurance the client picks will change their life trajectory.
One of the common areas where we work within our Venn diagram of responsibilities is in medication management. In my experience, most private health insurers follow whatever Medicaid/Medicare recommends, and then some will cover beyond that. For example, with diabetic medications, most commonly, insurers will pick whatever insulin they can get for cheap as the “preferred medication,” and then the more expensive formulations will get buried behind prior authorization requests or outright denial letters. Other areas where we commonly see insurance dominating are in imaging requests. In the last year or so, I have seen requests for peer-to-peer authorizations decline while outright denials have increased, in which insurance more likely states what the patient needs prior to getting an imaging study approved. On this issue, I feel the overall lag to the patient has decreased, as we often know what the insurance will recommend to the patient, and this is often faster than a peer-to-peer request, which takes time out of our day or adds to it at the end of the day, leading to less personal time at home.
On the corporate side of medicine, I oftentimes find myself having dwindling medical responsibilities, as corporate business types have sectioned medicine into “service lines” in an attempt to capture the most revenue from each part of medicine. This has led primary care to dwindle into mostly medication management while procedures have dropped off. Our office does not even have working lights in the procedure room; the one that we have is barely usable and looks to be ancient. We do not have safe hemostasis measures beyond silver nitrate applicators and some basic sutures, so any patient with an increased bleeding risk oftentimes gets referred instead of having their treatment done locally. Corporate health care types have removed my ability to practice obstetrics in the primary care clinic and have limited my procedural ability by limiting ordering supplies. Admin has also stopped my ability to practice OMT by giving me an exam table that is 200 years old and increases fall risk in the clinic, so OMT would not be doable.
On staffing, primary care clinics used to be staffed with RNs who were true assets to the physicians they served. Now, we have LPNs or MAs who have the most basic knowledge to be able to use the EMR and room a patient, but anything further than that is sparse. The most basic LPN instead believe they know it all since they have the degree of a nurse; this logical fallacy predominates in the nursing field and, unfortunately, causes mistakes in the clinic, with liability falling on the shoulders of the attending physician. Corporate MBA types do not wish to hire advanced nurses to help in the clinic setting, therefore, instead of wanting to pay the lowest, they hire the lowest skilled work that the state legalizes to practice in the clinic setting.
Most of my colleagues have recently lowered their hours, taking a pay cut to help them survive the onslaught of patient messages, Epic in-basket requests, forms, and insurance paperwork, and ever-increasing patient panels which are increased by money-hungry administrators who do not know how to take care of their physicians. The practice of corporate medicine is a profitable business, paying CEOs millions of dollars each year in salary, but at the risk of burning out the “cogs in the wheel,” the money generators, the doctors, and other providers.
The author is an anonymous physician.
