Sonoma County Medical Association
Sanjay Dhar, MD
What are the chances that a solo practitioner in the current toxic environment can make it against the Goliaths of the corporate healthcare world? Slim to none! With this thought in mind, and with an instinct for survival, three physicians and I recently huddled at a corner table in a fancy local restaurant with the CEO of a large healthcare network. After he presented us with pages of statistics from his shiny dossier, he lifted his glasses, sipped some Pinot, and said in a soft-spoken voice, “This is our last offer. We are the only viable game in town. If you guys don’t join us, we will find someone to replace you. I am not sure how long you can act like a dinosaur. You will become extinct or you will be assimilated.”
These words sent a chill down my spine, and my head started spinning. I felt as if the massive cybernetic Borg machine from Star Trek was here to eradicate our individuality and demolish what we stood for or offered to our patients. The CEO had all the numbers about our “performance” over the last three years. He had mathematical models predicting what our billing and collections would be like, based upon our current performance and insurance contracts. He also let it be known what we would be making sometime in the distant future, as if we were an amortized mortgage account statement. In all this mind-bending data, only one thing was obvious to me: All the graphs were pointing down.
The CEO raised his voice and said something that made him look like the ringleader in a caveman story: “We have Killer Insurance Contracts that you guys don’t have access to.” After a long night of reluctance to pay attention to any of his statements, I had to admit that there was some truth in his last utterance. The disparities in medicine in a free economy, such as ours, are particularly distressing for an individual practitioner who doesn’t have good contractual relationships with insurance companies. In layman’s terms, large groups are paid better for the same service provided by a smaller group or an individual practitioner. For some reason, insurance companies want solo practitioners to be assimilated or wiped out so that others can get paid more. The mathematics of this arrangement don’t make any sense, but it is nonetheless a bitter fact that I have to live with every day.
In the corporate-driven world of healthcare, graduates from famous MBA programs want to identify our patients as consumers or customers. We hand the MBAs practice satisfaction cards because some highly paid consultant told us to do so, but in the end we don’t even know what they do with the data collected. It’s like looking at the back of a truck that says, “Call this 1-800 number to let me know how I am driving.”
If I do get assimilated, what will my future be? In the current rush to reach cost-effective healthcare, the powers that be would like to treat us as factory workers and our patients as inanimate objects stretched out on a long assembly line. I will be forced to practice evidence-based medicine and follow predetermined clinical guidelines. Every day, I see patients who fall out of these well-defined boxes for treating chronic diseases, leaving me wondering who came up with those guidelines. I know that every patient and every problem is different and I can’t offer a ‘one-fit’ glove response to everyone. The irony of all these strict guidelines is that even after 2,500 years, we still don’t know the correct dose of aspirin for our patients. If something as simple as that is not clear, how we can thrust complex guidelines for complex chronic health conditions down the throats of our fellow physicians?
In this era of clinical data entry, I feel I have become a data entry clerk (with no disrespect to their profession). I didn’t go to medical school to become an expert typist. I find myself spending more time looking at the computer rather than the patient. I find myself struggling to make my clinical note longer so that I fulfill some random criteria for billing. I feel that I have to wrestle with the clock so I can mention that I spent 27.5 minutes with my patient. I fear getting penalized if I don’t mention that I did inquire from my 98-year-old patient if she smokes. The fear is that failing to ask would prevent me from getting a financial kick-back or a pat on my back from Medicare or other insurance company as part of some weird carrot-and-stick reward system invented by the echelons in Washington, DC. Why can’t I be rewarded for just taking better care of my patients? Why can’t I maintain my professional excellence and practice individualized medicine rather than toil as a factory worker who gloomily checks in and out every morning and evening? The lack of interest on our faces doesn’t behoove well for future generations who think it is a crazy idea to become a doctor. We have to attract creative, smart and independent thinkers who not only have expertise in science and biology, but also an authentic focus on humanism and caring.
The techie-driven 21st century exposes us to buzz words like ACO, cloud computing, CPOE, denial management software, EMR-EHR-HIT interoperability, meaningful use, creative destruction, satisfaction scores, affordable care acts, mobile healthcare apps and medical loss ratio. These terms not only don’t help my practice in any way, but they also give me a big headache and distract me from my primary focus of taking care of my patient’s problems.
Yes, I may be a dinosaur heading toward extinction because of tremendous economic pressures, long hours, hard work and impending Medicare pay cuts, all of which weigh heavily on physician-owned practices. It’s becoming increasingly difficult for us to run a profitable practice, spend time with patients and have a life outside of the office. It’s no surprise that about half the physicians hired out of residency and two-thirds of established physicians were placed in hospital-owned practices during a recent one-year period.
With so much talk about financial struggles and day-to-day hassles, it’s easy to lose sight of the positive side of being a physician. There are several reasons why we should be happy: we always have a job; our days are filled with variety, including diagnostic challenges and intellectual treasure hunts; we prevent illnesses as well as treat them. These reasons should give us a sense of pride and satisfaction. Patients still respect us, and we can act as great teachers, philosophers, friends and advisors.
But are physicians happy? To discover the answer, I recently conducted a 10-question survey of Sonoma County physicians. The survey included questions such as these:
• Are you happy in what you are doing currently?
• If you are not happy, then what will make you happier?
• What things would you like to see change in your career?
• Have you contemplated leaving your practice for greener pastures?
The bitter reality is that 90% of the physicians who responded to the survey said they were unhappy. Their answers were surprisingly different from person to person and from specialty to specialty. Here is one of the best responses:
We all complain about call. Most of us would rather not take call, even if paid a stipend. If we take call, the fewer the calls the better. However, most of us do what we do because the ability to help patients is deeply gratifying. Most of the time, the patients and their families are grateful that we are there when they need us and a simple “Thank you, doctor” makes the difference. Giving of ourselves to them is (or should be) more valuable to us as human beings than anything else we might actually do with that time we spend on call. It comes down to our society’s focus on the primacy of “me first.” Call seems burdensome not so much because it is physically demanding but because of the conflict between the deep desire to give to others and the societal pressure to “look out for ourselves first.”
According to my survey, the physicians in Kaiser and other large group practices seemed to be the happiest. When I questioned them further, however, I began to wonder if they were happy because they were ignorant of their true worth. If told exactly what their salaries were compared to the work they had put in or the revenue they had generated, they might not be so happy after all. But it was also obvious that they had taken that route because they wanted it that way and knew they were sacrificing something to get some element of happiness. In the end the survey did reveal the interesting fact that it would not take too much of a change for an unhappy physician to become happy or content with his or her style of practice. In our free style economy there is still room for Wal-Mart, K-mart and Nordstrom to co-exist and thrive successfully.
Meanwhile, I am keeping a close watch on my credit line and on the checks coming from the insurance companies. Private practices like mine are an important part of the varied healthcare topography. I would like some parity and respect for my individuality. Here’s to hoping that I won’t get assimilated. Beam me up, Scotty.
Dr. Dhar is a Santa Rosa cardiologist in private practice.
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