Tuesday, July 07, 2009

Are Doctors Sheeple?

Imagine a couple caught up in arguing about who should take out the garbage while there's a fire on the stove. The garbage may be a real source of conflict, but bickering about who's turn it is risks the house being engulfed in flames.

Such it was this past week when Daniel Palestrant, MD, Founder & CEO of the physician online forum Sermo, Inc., took a step in the wrong direction by deciding to stand in opposition (subscription) to the AMA:
As physicians, our first step in the healthcare debate needs to be clearing the air about who speaks for us on what topics. Today, I am joining the increasing waves of physicians who believe that the AMA no longer speaks for us. As the founder and CEO of Sermo, this is a considerable change of heart, given the high hopes that I had when we first partnered with the AMA over two years ago. The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country.
While some of his points might be perfectly valid, we wonder how further division amongst our ranks will affect our ability to lobby effectively for the doctors and patients in the current era of health care reform. Do we have the time for such pissing matches? I understand the inherent opportunity for Dr. Palestrant to mobilize the online physician community, but how do we mobilize the majority of physicians and break out of our specialty silos to develop points of consensus? Needless to say, the other partner, the AMA, was none too pleased and shot back:
The AMA has decided not to continue its business relationship with Sermo.

The AMA is always looking for effective ways to communicate with physicians. After an evaluation of the initial relationship with Sermo, we have decided that the value was not there to justify the investment of AMA members’ dues dollars. We continue to explore ways to communicate more effectively with all physicians.
Meanwhile, the politicians and lawyers smile.

This is not about "he said, she said." While Sermo boasts over 100,000 physician registrants, neither organization can say it represents the majority of doctors. Further, to suggest Sermo is any less conflicted than the AMA when it comes to revenue generation is misinformation. But all doctors are keenly aware of the bureaucracy, the middle men, the excess, cover-your-butt tactics needed to shelter them from litigation, their increasingly demanding work hours, frenetic patient visits and diminishing professional payments despite all of their work.

But now, all the politicos see is this: "Look Joe: Sermo guys ain't talking to the AMA and the AMA ain't talkin' to Sermo! Poor bastards. Guess we don't have to worry about them if they can't even agree with each other."

We are, after all, surrounded by professional organizations that have not permitted themselves to devolve into silos. The American Bar Association. The pharmaceutical lobby. The medical device industries. The American Hospital Association, etc. They have political clout. They have a powerful voice on the Hill. They know how to play the game. They have differences in political bents (trial lawyers typically democratic and corporate lawyers typically republican, for instance), but they know how to minimize their internal differences to maintain political bargaining power.

We, on the other hand, are fiercely independent, entrepreneurial, and schizoid: conveniently parsed into our narcissistic silos of primary care, hospitalists, nocturnists, specialists and subspecialists. Some are hospital-employed and others in private practice, some are academic and others fiercely clinical, some are deeply conservative and others even more liberal.

I have to admit I'm still miffed at the CMS proposal to cut cardiologists' fees and shift funds to primary care. I'm miffed at the AMA, too: where was their condemnation of the proposal?

But is this the big issue? To pretend that the cost of doctors' services are the reason for excessive health care costs is a chimera. Look on your latest hospital bill at the exact line items for a health care charge. Look at the "adjustments." Look at what the doctor ends up clearing for that bill. And that's all they can think of to cut?

Enough said.

On the other hand, as one commenter mentioned at the Happy Hospitalist blog in a post on why doctors' salaries are so high:
Take, for example, the Navy SEALS. As an elite unit, their work demands nothing but the absolute best of the best soldiers. In the midst of a shortage and recruiting crisis, the last thing the Navy should do is lower its standards in BUD/S to get more graduates to fill the demand. Lives are dependent upon the quality of the work that the SEALS do. In order to meet the growing demand for the SEAL ranks, the Navy has gone to ultra-marathons, 24 hour adventure races, and Ironman-type competitions to recruit the kinds of people who can hack it as a SEAL.

Medicine is no different. At a time when there are shortages across the board, why does it seem like the government and the industry have created less and less incentive for the best and the brightest to join our ranks? Arduous paperwork, debt, lawsuits, lack of emotional reward due to minimal patient contact, and the ever increasing leftist drone to decrease our income are some extremely powerful motivators to keep the best of the best looking somewhere else for satisfaction in life.
Getting doctors to argue about which among us should get the fee cuts buys into a myth that doctors' fees are the first and foremost reason health care costs are so high. Have doctors insisted on an intelligent discussion about true health care costs in Washington? Why not? Why are we being such sheep buying into the premise that doctors are the problem? Don't tell me that a doctor's pen is the single most expensive piece of medical equipment. Did my pen charge a patient a ridiculous $179,000 gross charge with a $43,000 "credit" seen on a recent 23-hour admission for a biventricular defibrillator implant?

No way. That's because the doctor's fee wasn't even included in the bill.

And what about the "Just To Be Sure" mentality that pervades medicine today? You know the one: "Mrs. Jones, I know you feel fine, but I think we should order another echo this year just to be sure your aortic insufficiency isn't any worse" or "Mr. Jones, we'd better check those liver function tests just to be sure your statin isn't somehow affecting your liver, even though we checked that test 6 months ago." Does the lack of liability reform and exorbitant malpractice awards force this line of reasoning? Dare we hold the politician's feet to the fire on this issue or do we just let the legal status quo with its ridiculous malpractice premiums continue?

I do not know what critical line was crossed that spurred Dr. Palestrant to sever his relationship with the AMA. Perhaps the damage is done. If so, God help us. But at this exact point in time, perhaps reevaluating and reconsidering the potential for reuniting the power of his forum with the established political standing of the AMA might be in the best interest to our profession, however staid the AMA might seem to him. With vigorous effort and collaboration, doctors might then have the ability to collectively voice their concerns to our political establishment and force policies beneficial to all physicians and their patients, rather than splintering our collective voice into impotent fractals of discontent.

Can physicians move out of their silos and develop consensus points we all agree upon?

The house is burning.



Keith said...


Everyone stood by for years while we in primary care sunk into the toilet. That is why you have the silo effect that you have.

If our specialty colleugues had rallied their societies to support us in our time of need, instead of packing more procedural codes into the CPT manual and railing about the idea that anyone would dare to cut their pay (which has been happening to us for years), I might be sympathetic. But now that the age of excess has ended with a bang, goverments will be looking to save a buck or two and that likely means looking at what European countries have done to contain medical costs. It is our willingness to pay big time for new tests and procedures and the cost of hospitals and specialists that are the big differences between here and there. There were three specialists at your hospital in the last reported year of 2006 (yes it does take along time for these non profits to get around to their tax returns) who made well over 1 mil and a whole bunch of guys in the executive suites that cleared 700,000 to 1.6 million; not exactly what you expect from a supposed non profit charity and not what you see elsewhere in the world. Times will need to change for the US to remain competitive, and that means health care costs will need to level out and likely will need to increase. You can't keep bleeding our businesses of excessive health care costs to support alot of this technological infrastructure, which doesn't add all that much to our health and often is not proven to be effective.

What you as specialists need to do is quit partnering with hospitals to drive up the cost of medical care (because, as you point out, it isn't the doctot that costs alot, but all the fancy gizmos that he orders or installs) and start looking at ways to offer this care in a more cost effective manner. Why else do hospitals put so much emphasis on cardiology and orthopedic services like they were the only two parts of your body that matter (maybe throw in some cosmetic dermatology and plastic surgery which REALLY adds alot of value to our overall health). Empahsize the things that will keep people healthy and out of the hospital. It doesn't mean we don't put pacemakers in people anymore, as I am sure I will be accused, but we don't let Medtronic charge us a bundle for the their newest pacemaker at twice the cost (kinda like do you buy the laptop with the newest/fastest chip in it at twice the cost, or will something at half the cost serve your purposes).

Thanks for the offer of solidarity as you stare at some pretty severe cuts from the folks in goverment. Maybe we in primary care can offer you some suggestions on how to cope since we have been dealing with it for a long time.

DrWes said...

What you as specialists need to do is quit partnering with hospitals to drive up the cost of medical care (because, as you point out, it isn't the doctot that costs alot, but all the fancy gizmos that he orders or installs) and start looking at ways to offer this care in a more cost effective manner.

Easier said than done. Not "productive?" Sorry, pay cut for you, dear doctor.

Patients, too, demand "the best:" "It's the latest model, right doc?"

I suppose I could not be an employee of a hospital and build my own lab... uh, oops I can't. I can't get a Certificate of Need here in the great state of Illinois. So I remain an employee, working in a big expensive fancy lab that lets me do the remarkable stuff that I do that certainly is expensive, but can actually CURE people of their ailment. Should I stop doing that, too, and just return to my internist roots for the good of the nation? Maybe we should just quash all the innovation from now on, too, since it's been so inherently evil and expensive.

Look, the I agree that internists are paid squat, over-burdened with P4P and dot-phrase development, onerous paperwork, pressure to see more in less time while seeing revenues cut, etc. I get it.

But our challenge is not to feel bitter that a specialist made (I doubt they still make, by the way) $1.6 million because he was an experienced CV surgeon or neurosurgeon, ran a department, and was recruited with a healthy signing bonus. That's how things are done in all of the business world. Rather, our challenge is to find common ground that benefits all doctors and their patients, be they internists or specialists to make sure the things we hold important, like excellence in patient care, tort reform, sane business conditions, fair compensation for our respective levels of training, expertise and hours worked. I agree we should work to constrain unnecessary building projects, drug and device prices, and hospital costs through transparency. That all makes sense.

But right now, health care outsiders on Capital Hill are spending $1.4 million A DAY lobbying our Congressional pubahs behind closed doors. Where are the doctors?

Suddenly, this spending orgy makes that specialist's $1.6 million annual salary look kind of paultry, don't you think?

Keep saying to yourself, Keith: "Doctors are NOT the problem."

Keith said...


Cardiologists have for years worked as independent contractors and not in direct employ of hospital systems. This has seemingly changed in the Chicago area and likely is the trend nationwide. It places the hospital administration in the position of calling the tune, deciding what equipment you will or will not have, and compromises the ability of cardiologists to be critical of those decisions (for fear of losing their jobs or just having administration make their life tough). As hospitals have evolved into buisinesses, they have brought a mangerial bean counter mentality to everything we do, which is probably why you feel like you are on a rat wheel as they squeeze more and more work out of you. Meanwhile, they are driving up costs and making a pretty penny on those devices you install. It is an incestous relationship where everyone plays along as long as everyone is getting their cut; but like the ponzi scheme on Wall Street recently, it is not sustainable or the best use of those resources.

You are right about patients wanting the latest gizmos, which is why comparitive effectiveness is so important in this equation; otherwise your friends at Medtronics will keep making the latest pacemaker that offers only incremental benefit, but at twice the price. Comparitive effectiveness will allow payors to intelligently disallow extra payment for devices that offer little value and medications that offer only small incremental benefit. Then insurers can say to patients, "you want that expensive new device or pill you saw on TV last week? Fine, but the extra cost will be billed to you, not your insurer.

Ther is an argument that also needs to be made, that some belt tightening may be long overdue. As you have pointed out in the past, there have been an enormous amount of building activity in the Chicago area as each hospital tries to out do the next with fancy new facilities. Frankly it is no different than patients wanting the newest fancy pacemaker; they also want the fancy newest hospital with the gleeming lobby and fountain. They just don't want to pay more for it.

We in the lower paying areas of medicine have been constrianed by these pricing pressures for some time, but have adjusted accordingly and still manage to eek out a living. You pay a health care system too much and what you get it lots of administrators running around in ther expensive suits and company provided Mercedes and giving themselves big bonuses and deferred income packages. Instead of being used to better the health care system and provide neglected services, What results is an overinfalted idea of the importance of management in running a hospital. I don't claim this job to be easy, but it is alot easier when you are making boodles of cash and can stumble a few times without going out of buisiness. I think we should be much more admiring of the skills of hospital administartors struggling along on limited resources in low income neighborhoods trying to provide the best they can for their commuity. Now that takes some real skill! Running a big, rich health system probably just takes alot of ass kissing (of the board) and selling enough of those fancy toys at a good mark up.

Anonymous said...

Divide and Conquer is working....unfortunately.

DrWes said...


I agree with you that the trend nationally is for private practice physicians to dissolve their practices and join larger hospital systems. But why is that? Might is be government requirements to purchase expensive EMR's? Or maybe the mandate e-prescribing? Or maybe the expensive requirement to perform and monitor P4P measures, lest practices not receive Medicare payments. Or maybe out-of-control malpractice premiums. Who are we kidding?

Are we really saving money with these bureaucratic endeavors or merely employing hoards of corporate sycophants at huge expense? Once implemented, can they ever be disbanded?

I have said before and will say again, if the government solution to our mess is more government, why the heck is Medicare going insolvent? Shouldn't we demonstrate a fix to that system first before investing scads of resources and trillions more in resources on a completely unknown health care delivery model?

But instead of asking these questions, people bicker about the "incestous relationship where everyone plays along as long as everyone is getting their cut."

News flash. Given the current lobbying efforts underway with the administration, that won't change in the new system either. But you, dear doctor, will be squeezed like never before as more and more "requirements" are added to the covert rationing scheme being developed in an attempt to "save" money.

Futher, to think that CER is the salvation for cost containment or better safety or utilization of resources makes a mockery of the virtually infinite confounding factors that are always in play in an individual patient's health care delivery. While you are comfortable with insurers being the ones to make decisions for your patients, I am less so. Further, it would be far cheaper to look up any needed research up on the internet and make an educated decision that pertains to the individual patient's circumstance, rather than believe the results of a single CER study with inclusion or exclusion criteria that do not pertain to my patient. Will insurance carrier receptionists be able to discern these subtleties? They certainly don't now. What makes you think the future will be any brighter?

Keith said...


This we agree on that the requirements that are being foisted on us will require more management and concentration in larger organizations to manage. this all will kill the samll office practice. But that does not mean that physicians cannot call the tune with management working for them rather than visa versa. You get MBAs running the store, then your focus is purely on what is profitable. You get physicians in charge, then hopefully you get a better sense of what is valuable to patient care and where dollars should be applied. That has been the successful formula of places like the Mayo Clinic which was founded as a clinic run by doctors, and you will see that their board of directors continues to be doctors, not prominent buisiness people who come out of the same mold as hospital CEOs.

Medical groups can be run separatly from the hospital and should be able to counterbalance what hospitals do. When the hospitals owns the docs and their revenue stream, then it is difficult to buck administration. I will bet you've seen alot of unhappy docs straining at the grindstone of managerial edicts and many who have left in discontent. That appears to be the only way to raise objections within these integrated systems is voting with your feet.

Anonymous said...

mayo clinic is financially strained too, despite their unmatched fundraising.

aren't mayo docs employed by the hospital? i recognize that you think that a board made up of doctors differs from other boards, but your point about difficulty bucking the system would still apply to them.

Keith said...

Hey Anonymous,

there will always be friction, but I would think the mindset of docs and MBAs is radically different. All are motivated by money to some degree, but MBAs are coached in growth and profit making and seem to be overly rewarded for both.

Christopher M. Hughes, MD said...


You go, boy!



Anonymous said...

i am not sure the mindset for the ceo/mba is so wrong. someone needs to be the guy who balances the budget and makes sure the work gets done. it is still a business after all.

Anonymous said...

IMHO, doctors are the least of the health care mess. Part of the problem is the private insurance industry. It takes a whole lot of call center staff, claims 'adjusters' and the like to perpetuate the unending negotiated rate/pre-authorization/network/formulary bureaucracy and preserve profit margins, exorbitant salaries, venture capital funds, and banks. Dealing with health insurance companies reminds me of Terry Gilliam's movie Brazil - my premium dollars vanish into the bowels of the beast, conveyed by pneumatic tubes, never to be seen again. I just don't feel like I should have to whip out a CPT or ICD-9 manual to get the insurance company minion off the dime. (Been there, done that, got the t-shirt.) And you drs get to have even more administrative fun! It doesn't help that the majority of IL insured are covered by the same company, either. Too much clout is wielded by a single company... Hospitals are part of the mess. How about the Fair Billing Act? Edward Hospital must give over 50% discount to uninsured pts that meet the criteria. Of course, they have fancy new digs, and continue to add facilities. Let's not mention the idiocy of both NIU and CDH and their competing proton beam facilities within a 5-mile radius of each other. Do we even need one proton beam facility here? Someone thought so - I guess they heard Loma Linda's advertising as many times as I have. The drug companies and their 'ask your dr' ads are another part of the mess. Ask for more expensive, not necessarily more effective drugs where a generic might suffice. Don't forget the lawyers - since all doctors are filthy rich, any pt with a grievance can win the malpractice lottery!

You're right - everybody other than drs and pts have effective lobbying groups, many of which are headquartered right here in Chicago: AMA, BCBSA, AHA, ABA, AHIMA, CCHIT, and the rest of the alphabet soup.

Argh! It's enough to give anyone high blood pressure!

Jessica said...

What an excellent post. I for one want to hear what the physicians have to say and really, that's about the only group I want to hear from. It is beyond comprehension how people can condemn doctors/providers for health care costing too much. It makes me so mad - it is the best case of brainwashing I've ever seen and it would do us well to track that sentiment back to those who stand to gain the most from spreading such lies.

We are lucky to have the talented souls who go to work each and every day knowing the tape they have to work around and we need to stop now and listen to what they suggest. There is too many unnecessary layers between me and my providers, too much between me knowing how much something will cost so I can plan ahead, too many back room deals between unaffected players that help those who don't need it and hurt the ones that are dying for help.

While reading your post, I got this picture in my mind of like, all the great doctors in our country with their nose to the grindstone, doin' their thing, working their magic, not having the time to 'make deals' like power groups have time to - like you said, they are being the entrepreneurs, the innovators, the individuals who are healers and kind souls who set out on a mission to help people live their lives a little better than the day before. All the while, those who are not intrinsic to the provider/patient relationship are spending their time buying political capital. The individual-ness of doctors is what makes medicine in our country so great - your minds are free to work! No associations required, just more volume please!

Please forgive me if I offend anyone with this rant. I am not in the medical profession nor am I in politics. I just love my doctors and my local pharmacy and I don't want them to get lost in the wave of politics and pissy-ness. :) I'm 'lobbying' for you guys - for people to shut-up for two seconds and ask a doctor, "Hey, what do you think?" :)

Latino Manager said...

"I agree with you that the trend nationally is for private practice physicians to dissolve their practices and join larger hospital systems."

This is not necessarily the case for us in California where the IPA is alive and well and does exist to a smaller degree in other parts of the US.

There is a national movement about called Physician Groups for Coordinated Care that will become the competitive alternative to hosptial systems/foundation models in primary care practices.