Games People Play

Medicine is a business. Believe me, as a doc in solo practice I REALLY understand that. I want to help people, but also have to pay Mary & Annie, and my mortgage, and Diet Coke bills, and office rent, etc.

In a perfect world, healthcare would be free and unlimited. But our world isn't perfect, and the issue becomes balancing finite dollars against virtually infinite need.

We all try to do our best (I hope) to care for patients within our means.

Unfortunately, the system gets abused from all sides.

1. Insurance companies sometimes try to rip-off doctors and hospitals (and many others in between).

2. Hospitals and doctors (and many others in between) sometimes try to rip-off insurance companies.

3. Futile care is often given, usually due to family members feeling guilty. All of us in this business have seen a 90+ year old person with advanced dementia and other serious medical issues, being kept alive with machinery at a family's insistence.

4. Unnecessary admissions for bullshit reasons are common, and a huge waste of resources. My esteemed colleague ERP recently wrote an excellent post on this over at WhiteCoat's Call Room.

5. In my career I've known some system-abusing nurse managers. For example: Years ago I worked at a hospital where one floor's nurse:patient ratio was supposed to be 1:4. Instead, it was often 1:5 or 1:6. This lowered quality of care and increased nurse burn-out, and most docs sure noticed it (I don't go to that hospital anymore).

At a meeting to address these concerns the floor manager was asked why this problem kept occurring. She explained to us that her year-end bonus was based on how far under-budget the floor was, and that she needed to run the floor understaffed because she was trying to afford a down payment on a new car.

6. Some insurance companies have policies where doctors are paid a bonus based on how much care they DON'T do (I don't participate in those contracts). In other words. Big Insurance, Inc., says to Dr. X. "Here is $100,000 (hypothetical number) to pay for all our patients' tests this year. If you only spend $75,000, then you get to keep the other $25,000."

This is grossly unfair. In a perfect world the doctor would ignore this. But it ain't perfect, and we all have bills and families, and so it puts the doc in a difficult situation. And of course, if he doesn't do a test and gets sued, who gets nailed? Not Big Insurance, Inc.

These contracts, fortunately, are in rapid decline. They were most popular during the 90's. But are dying now as more and more docs refuse to accept them.

7. Pay-for-performance (also called P4P). This has been kicked around in the last few years. The idea is simple. Docs who have good patient outcomes will get paid more. After all, shouldn't they be rewarded for being better docs?

The problem here is that some conditions are basically untreatable. And some patients don't care about their own health. If something like this happened, WTF would I want to see someone with something incurable, like Alzheimer's disease? I'd only want to see simple stuff with generally good outcomes, like a young, healthy patient with carpal tunnel syndrome or occasional migraines.

If you've had a stroke, or brain cancer, or something else that ain't so good, then good luck finding a doc who's going to take you on with P4P. Because sick people are only going to cut doctor reimbursements since their outcomes will be worse. And, like I said, in a perfect world docs wouldn't look at the bottom line. But in this world we all have bills and families.

Not only that, but if I beg Mr. Marlboro to quit smoking, and he doesn't, and has a stroke, then I get penalized for a poor outcome that was out of my control.

For P4P to work, it's going to need A LOT of tinkering.

8. And my last whine, and the one that got me thinking to write this:

I got called to ER early yesterday morning to give an older gentleman TPA, the clot-busting drug. He had right-sided weakness, but fortunately got better on his own. Later in the morning, however, he worsened again, then got better again, and kept fluctuating. I kept running back & forth between my office and the hospital as the situation changed. I finally got him stabilized with medications, and ordered a bunch of tests (MRI, MRA, echocardiogram).

About 6 hours after I left the floor, I got called by Dr. Hungry Hospitalist.

Dr. Hungry: "Yeah, this stroke guy. Can I send him home now?"

Dr. Grumpy: "He hasn't had any of his tests yet, has he?"

Dr. Hungry: "No. Can't you just do them as an outpatient?"

Dr. Grumpy: "I'm not comfortable with that. He needs a work-up. His last TIA was only 6 hours ago, and I'm not even sure he's neurologically stable at this point. It's too soon to see."

Dr. Hungry: "I'm sure he's stable. Can't you just see him in your office in a few days?"

Dr. Grumpy: "Why are you so eager to toss him,?"

Dr. Hungry: "Um, well, uh, my, um, year-end bonus is based on how short I'm able to keep my average patient length of stay, and I had a really sick lady a few months ago who was here forever, and blew my average to hell, so I really need to bring it down because I've got a med school loan lump sum payment due in January and..."

I hung up on him.