The medical profession has gone through major changes from the days-past to present days. The transition from quackery to science, and from role assuming or inheriting to regulated graduate and postgraduate education.
The changes took place over centuries, but the most notable evolution in medical knowledge and training took place in the last couple of centuries and continues to evolve. Evolves may be used to describe positive as well as negative changes.
On the positive side, one can list some of the far-reaching victories of medicine such as: increasing median life spans, development of vaccines, and reducing death rates of various malignancies, development of antibiotics, organs and body parts transplantation and implantation, and, most recently, the introduction of robotics, and artificial intelligence (AI).
On the negative side, one can characterize some the changes in our noble profession as steps back, or “un-noble.” Few of these negative steps in our current evolution can be found in the areas of delivery, quality, and accessibility to quality care, personnel shortages, and biases in research. Most of our colleagues, patients, the media, and other observers label these changes as the commercialization of patients’ care by intruding profiteers and business entrepreneurs into medical care.
The reasons behind some of these negative developments cannot be blamed totally or in part on any individuals or groups. It is up to the reader to quantify the distribution of blame on each of these groups/entities.
Physicians and extenders
Some HMO “providers” did not refer captive patients to specialists, or expensive testing, when needed, to preserve the maximum bonuses from the insurers. Others have advised their bonus depleting patients to switch back to Medicare or PPO plans. Physician extenders ordered unnecessary tests causing delays in treatment and occasional harm in addition to increased cost. Hospitals’ employed “providers”, went along with their employer’s unwritten demand to refer their patients, exclusively, within the system. Others adhered to their shifts’ timing, thus refused to treat patients needing their immediate attention, because their shift was nearing its end. Yet, other providers have elected to enter the field because of higher earnings potential and chose the highest paying specialties, not because of admiring the services they will provide, nor compassion for patients, and serving their needs, but purely for financial goals.
Insurance companies
Insurance companies raised premiums, restricted coverage, wasted office and hospital staffs’ time, and frustrated patients through the loops of pre-authorization, denials, and delays. They harassed physicians by requesting them to appeal and attend endless hearings to get their prescribed treatment finally approved. Additionally, they delayed payments, disapproved services provided to their enrollees, even after the services were pre-approved in writing.
Hospitals’ systems consolidations
Hospitals’ multi-level executives, and managers misled our legislators, and regulators to believe and eventually approve their mergers into large systems for the purpose of reducing costs and improving care. These consolidations, of many hospitals into few systems per region resulted, per many published studies, in exactly the reverse: higher cost and worse care. Additionally, as an adverse side effect, it led to the closing of many rural hospitals and vanishing of local care in many underserved and rural areas.
Governmental regulations and hospital systems employment factors
Medical school-related issues
a. Inadequate governmental financial support of medical schools resulted in a significant increase in tuition, coupled with increases in the cost of living, and inflation. The cost of attending medical school resulted in an average medical student’s loans exceeding $250,000. More recently, the U.S. government limited the amount medical students can get for low interest loans to $50,000, per year, while tuition only in various medical schools averaged in the mid-70s. b. Lack of interest among our legislators, over the last few decades, to increase the funding of post-graduate training spots. These funds are an integral part of CMS budget. c. Deep cuts affecting research funding at NIH and other funding sources. These cuts affected researchers from pre-med students to professors. d. Continuous drops of Medicare reimbursement to the clinical faculty. e. Low salaries of medical graduates during the minimum of 3-7 years of post-graduate training (average working hours per week estimated to be a minimum of 60 hours). Low incomes led to increased debt owed by these already financially burdened new graduates. Additional debt will incur if medical graduates choose to start a family, buy a house, and a more efficient or comfortable mode of transportation.
Other hospitals’ related issues
a. Given the vast wealth of hospital systems, their market shares, and hospitals, regardless of their profit status, became the best salary-wise employer of choice. b. The new “docs-on-the-block” who even considered an alternative practice settings, discovered less attractive initial revenue, and higher loan payments in starting a new independent practice, or, lower first year salary if joining an established independent practice. c. Hospitals’ anti-competitive war on independent physicians and on their medical staff. The war was launched on several battlefields depending on specialty, success of independent practice, age of practicing independent physician, and other factors that will be discussed later. d. Hospital employer hospitalists, facing no competition from independent hospitalists. e. Employed physicians are indirectly instructed to limit their referrals to “providers” within the system. They were also limited, along with their immediate families, to be cared for only by “providers” from within the system unless they purchase a much more expensive health insurance plan. f. Employed physicians in most of these hospital systems are offered bonuses and incentives for referring their patients for lab and diagnostic tests to keep the various departments within the hospitals busy. g. Anti-competitiveness, within these corporate giants, is engineered by their profit only incentive to remove independent physicians from their medical staff, when the system acquired another “employed provider”. h. This practice is known as “ours must prevail policy.” i. In practical terms, managers and department heads, in cooperation with others in the system start a “witch hunt” campaign against the designated target. Their tools consist of writing adverse reports about the physician, whether valid or not, to start harassing the competing independent physician. The written reports are circulated through various medical staff committees, composed of an un-defeatable majority of employed physicians and in some cases, APRNs, and an administrator to streamline the game plan and assure its success and document the identity of dissenter(s). These tactics assure the executives of the system of gathering enough fabricated or exaggerated tales to harass the independent physician all the way into resigning or placing restrictions on his or her practice. In doing so, they guarantee their employed physician a free ride to meet targeted budget without any embarrassing competition and criticism-free surroundings. j. Hospital systems’ executives will pressure various committees of the medical staff to bend the rules to accommodate their profit-driven plans. An example of this practice was observed recently when a hospital within a system forced the credentialing committee to grant surgical privileges to a surgeon who left clinical work for over two years. The committee, composed of employed and contracted physicians and APRNs, accepted, under pressure, to grant the surgical privileges based on the employed surgeon’s residency experience several years ago. k. Employed physicians within a specialty or location become subordinates of a manager who reports to the hospital executives. The office manager has always the final word.
Corporate medicine has stripped medicine from its humanistic characteristics by putting profit first instead of compassionate care. Meanwhile the latter prominently is only displayed on their websites and in the media, to secure subsidies, grants, and donations from all possible donors. The websites lead visitors to believe that those charitable organizations and sisters’ orders are still running the systems. Many of the not-for-profits pose as religious organizations by listing the founding organizations, ignoring to disclose that the founders had left the hospitals many years ago. The last report, by the U.S. government, disclosed the estimated taxes that these Hospitals avoided to be over $37 billion. Most recently, private equity companies have started buying lucrative physicians’ practices and transformed the physician into a management supervised “Pac-Men” to meet the appetite of the investors.
While these changes are evolving in the U.S., my aim from this editorial is it raise awareness worldwide to some of these shortcomings, in hope of alerting the practitioners of this most noble profession to protect its “nobility” from the various intruders driven by greed.
This article was originally published in the Journal of Dermatology & Cosmetology.
Edmond Cabbabe is a plastic surgeon.
