WHAT’S REALLY WRONG WITH HEALTHCARE

I learned about healthcare from my father, an old-time family doctor who began each day at the hospital doing rounds, i.e. seeing his patients who he had hospitalized for a variety of reasons.  As a surgeon and obstetrician, he also performed appendectomies and delivered babies there.  And of course sometimes, inevitably, he shepherded the end of the end of a patient’s life.  The hospital rounds were seven days a week, rain or shine or snow.  This was Chicago for god’s sake.  On Monday, Tuesday, Thursday and Friday, he was in his office for morning, afternoon and evening sessions.  Yes, Friday evenings, too.  And for a number of years, Saturday morning as well, until my mother put her foot down.  Friday evenings eventually stopped when I was in middle school.  After the evening office hours, he would make house calls.  For those of you who hare not familiar with the term, a house call was when the doctor came to your house with a black medical bag to treat whatever illness prevented you from coming into the office.  The charge for a house-call in the 1950’s was $5.00.  As you can imagine, time with my father was at a premium and so, in my preteen years, he would take me to the hospital on Sunday mornings after church where I would make rounds with him or “help” the hospital admin staff by redirecting canisters carrying medical records into vacuum tubes that sent them all around the hospital.  Hi-tech in those days.  I would also accompany him at times on house calls, where I would wait patiently in the car for him to finish.

That was his life and also ours because the need of the patient always came first.  We had two phones in the house.  One was our house phone and the other, the red one, was an extension from his office.  Stanley 8-9393.  I hated that number.  To further complete the picture, my vivid recollection from childhood was my mother, sisters and I waiting in the living room for my father to resolve some medical emergency before we could go out to dinner or a movie.  Back then, the doctor had to guess whether the appendix was going to explode or the pregnancy was ectopic and therefore life-threatening without surgery.  A further complication was that there were no cellphones or even pagers so, wherever we went, my father had to be near a landline that the answering service could reach in case of an emergency.  There was no 911, only Stanley 8-9393, so if a patient cut themselves or broke a bone, they would call my father and he would meet them at the “accident room” where he would suture their cut or set and cast their broken bone.  Such events were not scheduled and so my father would have to drop everything to go to the ER, often that meant cancelling or postponing our family functions, something we all understood and accepted as patient care always came first. 

I want to share a vignette about the “accident room” that really exemplifies the difference between healthcare then and now.  It is also the moment in my father’s professional life that I am most proud of.  The accident room was just that, a room divided my curtains on rollers that separated the larger room into small sections where the doctor could treat their patient.  My father was finishing up with his patient when he heard the doctor in an adjacent area say to the patient: “we’re going to have to amputate the finger”.  My father pushed aside the curtain and said: “let me have a look at that”.  He then went on to save the man’s finger.  I heard this story, not from my father, but from the man whose finger he had saved, who was replacing the universal joints on my car as I was travelling from Rhode Island to Denver for my internship.  How extraordinary.  How many doctors today would insert themselves into a clinical situation, uninvited, to try to help?  No concern about malpractice.  Just a desire to help a patient in need. 

The hypocritic oath in my father’s life was “DO GOOD”.  Doing no harm was assumed. 

Today, the primacy of patient care has largely been lost.  Medical practices close at 4:00PM.  If there is urgency, call 911 or go to the ER.  Whatever happened to doctors like my father.  Some of it is the general erosion of pride in the quality of work that pervades our society but the greater part, in my opinion, really stated with Obamacare and the advent of ACO’s, Affordable Care Organizations.  The architects of Obamacare were either not physicians or they were not practicing clinicians.  They believed that organizing healthcare into large systems would streamline processes, improve efficiency and presumably lead to better care.  I accept the good intention but the only part of the healthcare system with the resources to become an ACO were the hospitals.  Hospitals are the least efficient and most expensive part of healthcare.  Hospitals are where a bandaid costs $4.00 and a procedure done in the office costs a fraction of what it does in the hospital.  And so, with the blessing and financial backing of the federal government, hospital systems began buying up healthcare, including outpatient practices and making employees out of physicians and other independent providers and fixing costs before even one patient steps through the door.  While I was at Blue Cross of Rhode Island, there was an ongoing debate about the virtues but mostly the vices of the fee for service system in healthcare.  The critics cited the conflict of interest in which providers were paid more the more services they provided.  My point was that the financial incentive of being paid in direct proportion to services provided was an important motivator that benefitted the patient.  Employees are less likely to come in early and stay late.  In a hospital, when the shift is over, everybody leaves.  This is what the ACO’s have done to the small, independent medical practice that used to be the heart of healthcare delivery.  I used to say when you add a second telephone line, you change the practice and not for the better.  My PCP has just changed practices i.e. changed owners after the conglomerate that had bought his practice took his name off the door after twenty plus years and replaced it with the company name and logo.  Another PCP I heard about left his practice in Rhode Island to become a concierge doctor after Brown University Medicine purchased his group practice and required him to see 28 patients in an afternoon.  Nothing about the quality of care, only the quantity.  Another colleague of mine just left her position as director of MRI imaging at an ACO after over twenty years because the administration was only concerned with “productivity”, nee income, and not enough about patient care.  Her priority had always been patient care and the clash was ruining her life. 

So where do we go from here?  I wish I had an easy answer.  When I began managing the mental health effort at Blue Cross of RI in 2000, I told our providers that we were going to revalue psychotherapy and one of my first actions was to remove authorization and review of outpatient mental health.   Managed care at least on the outpatient side, was a costly and ineffective intrusion into clinical practice.  It had never been shown to reduce healthcare costs or improve quality and fortunately does not exist today except in rare circumstances where true believers think, without facts, that it must be effective.  In my twelve years at Blue Cross, I was appreciated by the provider community for bringing a clinical dimension to the decisions we made about care and coverage.  When large hospital organizations or insurers own labs, pharmacy benefit managers or provider practices, their focus and priority is the bottom line and patient care can easily be lost.  When my father practiced, healthcare delivery was bottom up, not top down as it is today.  Insurers often get a bad name when discussing the problems in healthcare but large delivery systems that inevitably neglect patient care because of their focus on finance may be the greater threat.  Consolidation and merging in the interest of efficiency leads to impersonal care.  When an office had only one telephone line, you likely spoke to a real person.  Now it’s a voicemail tree with no live person even available.  When the decisions about care are made by the treating provider, the result is much more likely to be appropriate.  When they are made by algorithm or on the thirty-second floor, often they are not.  At Blue Cross of RI, I wanted to replace managed care concurrent review with a consultative model in which we, the insurer, collaborated with the provider about treatment.  To fix healthcare, I think we need to return to a patient care oriented approach which relies on the on the informed judgement of the treating provider for treatment planning and decisions.  To this end, I would forbid ownership of outpatient practices by insurers, ACO’s or any other third party.  In other words, to reverse the structure established by Obamacare which I believe has stripped healthcare of its patient care focus and escalated costs to the brink of bankruptcy.