Friday, January 6, 2017

Do Businessmen Dream Of Medicine Without Doctors?

You bet they do.

My first exposure to the business-driven dystopian future of medicine occurred in Fort Lauderdale in 1994.  I was the Public Affairs rep for the Minnesota Psychiatric Society.  The APA decided that it would be a good idea to bring all of the Public Affairs and Legislative reps of the local district branches (DBs) to Florida for a conference.  On the surface it was supposed to be focused on getting solutions into the hands of the DBs.  In retrospect it was a shocking introduction to how the managed care industry would lay waste to the field of medicine in the decades that followed.

The keynote speakers for that conference were Governor Arne Carlson from Minnesota and a business consultant.  Minnesota has always been a hotbed of managed care activity and for the past three decades any physician practicing here has been a witness to what can happen when government and business bureaucrats practice medicine.  The end result of rationing psychiatric services over that period of time has been a system of care that is so fragmented and that provides such poor service to patients and family members that the current Governor Mark Dayton recently called for massive reform.  The result of that Task Force is quite unremarkable but that is another story.  In 1994 Governor Carlson was there to brag about MinnesotaCare, a government insurance scheme for the working poor and the Health Care Provider Tax on all health care providers in the state to finance it.  He was describing them as major breakthroughs but over the years they have proven to be very suboptimal programs.  The Provider Tax in many years acts as another revenue source for the State and that revenue is not directed at anything to do with health care.  I have never witnessed any of my working poor patients get on MinnesotaCare.  It appears to be rationed as tightly as a managed care option.  Some members of the audience were less than receptive to these ideas and the Governor did what he could to put them in their place.  The precedent of never telling a politician that they are wrong about their supposed health care reform was easily established.

The consultant provided an even clearer picture of the business agenda. He bombastically presented the first wave of fake news that helped establish managed care.  That fake news was - "Nobody needs specialists anymore.  There are too many of them and they are too high priced.  We are going to buy them out and put them out of business.  The only doctors we need are primary care doctors."  He focused on orthopedic surgery as a case in point, but he pointed out that the same was true of any medical specialty.  It was an implicit threat to all of the psychiatrists in the audience. Of course his statement was pure fabrication.  There is no way a businessman is going to spend a dime to buy practices when he can just manipulate them out of business.  It was the beginning of the full court press to manipulate physicians into doing whatever the business types wanted them to do.  In the following 2 decades - physicians and patients were manipulated into using primary care physician offices for a gatekeeping function for everything while simultaneously reducing reimbursement to those physicians to the point that they needed to see 30 to 40 patients a day to keep the doors open.

I was working for an altruistic multispeciality clinic at the time.  I say altruistic because one of our goals was to see all people presenting to our hospital or clinic irrespective of their ability to pay.  We had to work harder as a result, but were generally quite content.  The physicians were high quality and we were all collegial.  I never trusted any group of physicians more.  The work environment resembled the training environments that I had worked in - county hospitals and VA hospitals and clinics.  Billing, coding, and reimbursement were far removed from the work.  We had billing and coding specialists who came by, read our notes, and submitted the billing documents - totally unseen by us. All we had to do was focus on the practice of medicine.  Anyone working in those days would tell you that was more than enough.

But there was fear in the air.  Over the next several years the physicians in my group were talking about how the local managed care companies were going to put us out of business.  Since were were the largest provider of medical and psychiatric services in the east Metro area and had the market cornered on poor reimbursement,  I dismissed it as hysteria.  Over the next several years we were acquired by one of the three managed care companies that provide the bulk of medical services in Minnesota.  In the process our self funded malpractice fund disappeared.  The provision of care also started to change.  There was no longer an acute care Neurology service.  Stroke care was going to be provided by "an internist with an interest in strokes."  The internal medicine consulting service became the hospitalist service and primary care physicians no longer saw their patients in the hospital.  The decisions were not discussed.  There was no consensus.  Department heads were let go.  Physicians were just told what to do.  At some point my request to talk with the wizards behind the screen was met with a simple answer.  There was now a "firewall" between physicians and the administrators and there was no way that I would ever question their decisions or talk directly with them.  

The administrators began to proliferate.  An endless series of administrative ideas began to be put on the physicians.  Physician were no longer practicing medicine all day long.  Suddenly there were plenty of feel good meetings for administrators.  And so it went.    Outright bombastic contempt for physicians was no longer necessary.  The administrators had won.  Additional mechanisms were put in place to suppress any dissent.

The contempt is still palpable in some of those dissent suppressing situations.  These days - all it takes is a complaint against a physician to activate what is typically an airtight mechanism to scapegoat them within the organization.  It doesn't matter if the complaint is real or not.  In many organizations, a physician's annual evaluation actively solicits anonymous complaints about them.  It is part of a general effort by administrators to illustrate that physicians are really deficient human beings, only able to function in the context of a beneficent organization and supervision by a business person.  Some organizations have a "three strikes and you are out policy" and they don't want to debate the merit of any complaints.  They just list it as a strike.

This is how being a physician devolved from being a fairly autonomous profession to one that is clearly under the boot of the managed care industry and the government and everything that entails.  It was largely an exercise in fake news and rhetoric on the part of the business community and a complete lack of response from physicians or their professional organizations.  That practice is alive and well today.  There is no science involved in business management and no standards.  That alone would create some suspicion about how medicine is currently managed - but there are very few critics.  Physicians as a group have never been able to grasp one of management's unscientific techniques referred to as pushback.  Instead of standing there like deer in the headlights pushback against all of the fake news generated by these managers.

If that ever caught on with my colleagues - we would all start pushing now and keep it up for the next 30 years to just break even.

George Dawson, MD, DFAPA

Supplementary 1:  Businessmen here is used as a generic form of businessman or businesswomen.  There are clearly plenty of female managers who also do not know what they are doing.

Supplementary 2:  A few words about pushback.  According to William Safire writing in the New York Times - pushback the noun began to surface in business journals near the end of the 20th century.  In my experience it started to show up in medical meetings about a decade later.  The current Merriam Webster definition is "resistance or opposition in response to a policy or regulation especially by those affected".  That does not really capture the business application of this term.  In a business meeting for example, the strategy might be to exert some kind of pressure on a group or subgroup of people affected by the business and see if there is any pushback.  In some cases, no pushback is expected because the employees are fairly expendable.  I heard a business story about retail stores that use a clopening strategy where the same employee closes the store one night and has to open it in the morning.  That is very inconvenient if you are that employee and trying to coordinate daycare for children or a second job, but pushback is not really anticipated.  In the case of professionals who are required in certain positions pushback might be anticipated with certain mandates.  I have been in meetings where the question was asked: "Has there been any pushback from the doctors or nurses on that?"  If there is none, the leverage is typically increased until there is.  In the case of physicians it rarely (if ever) happens.  There have been numerous explanations for the lack of assertiveness on the part of physicians.  The general explanation is that it is unseemly behavior that is inconsistent with the professional image of the physician.  I think the real mistake is that physicians assume that the business manager class has the same degree of professionalism and values when they clearly do not.  Any physician being pushed around or bullied by business managers knows exactly what I am talking about.  They do not think or act like physicians.  It is time to stop acting like they do.


William Safire.  Pushback.  New York Times.  January 14, 2007.    

Supplementary 3:  From Orwell's 1984 as O'Brien interrogates Winston Smith and plants the idea that the only way man can assert power over another is by making him suffer and goes on to detail how that is done.  He concludes:  ".....Always, at every moment, there will be the thrill of victory, the sensation of trampling on an enemy who is helpless.  If you want a picture of the future, imagine a boot stamping on a human face--for ever."

That is exactly where the business world and the government want the medical profession.


George Orwell. Nineteen Eighty-Four. A novel. London: Secker & Warburg (1949).

Attribution:  Image from this post is downloaded from Shutterstock  per their standard licensing agreement.  Image number 59502138 by Stokkete (photographer).


  1. Doctors are basically fearful, obedient morally masochistic and bad businessmen.

    Businessmen are ruthless, and many are bad businessmen despite an MBA and well developed line of BS.

    You do not need an MBA to be a good businessman. You sure as hell need medical school and training to be a good doctor. Yet we are stupid enough to not get in their faces...because that would be...unprofessional?

    Medicine is the only field in the world that has ever gone on a thirty year run of failed cost reduction by radically increasing the number of managers and middlemen. You don't need an MBA or even a sixth grade eduction to deduce how insane that idea is.

    This goes to my point responding to the post below. There is no cost reduction without addressing this:

    US health care costs also went off the rails in 1980 which was about when HFCS made a major push into the American diet.

    This does not give me hope about single payor. Single payor will sell out to the highest bidder, because that's the pattern of government behavior. CMS does not give a damn what doctors think.

  2. "Doctors are basically fearful, obedient morally masochistic and bad businessmen."

    If true - none of that needs to translate into being ordering around by people with no ethics or scientific basis. The key skill that doctors lack in the 30 year lost war is not being able to recognize fake news or rhetoric. The fear I describe in the above post was basically fear over the second round of fake news from managed care bureaucrats and their considerable friends in government was: "The times are changing for physicians - they are no longer in charge!"

    What! Let me get this straight. Physicians are no longer in charge because you say they are no longer in charge. The appropriate response at that time would have been full of expletives - but by then some of the best physicians out there were shaking in their boots.

    The explosion in managers is now legendary. Himmelstein and Woolhandler have a graphic showing the increase of administrators under managed care was 3,000 %. (thanks you for the link to the KFF version of this). The wreckage is equally legendary but nobody points out the connection. When the USA did so poorly on the WHO report 10 years ago - nobody pointed out that this underperformance was the direct result of 20 years of managed care. I have documented the toll in Minnesota with one of the poorest systems of care for mental illness in the country due to managed care. But we are collecting everybody's PHQ-9 scores through the DHS!

    True single payer will not be run by for profit proxies. The bureaucracy will need to be contained and not rewarded for rationing. All of the healthcare systems on the chart from my previous post have been studied. The system can be reconstructed from a public health perspective without the pernicious effect of American businesses that as far as I can tell have added absolutely nothing to the provision of health care in the USA.

  3. Another thing about single payor...all indications are that psychiatry under single payor will be Collabo-care. I would never personally participate in that as a patient, and warn others not to either.

    So basically it will be like the school system...mediocrity for most while the elite send their kids to private schools.

    I guess this is good news for those of us with cash practices. Bad news for public mental health though.

    1. Per my suggestion - none of the countries in the graphic have collabo-care psychiatry as far as I can tell. The Swiss have 3 times as many psychiatrists as the US and this article correlates their use of psychiatry with their longevity. That is an admittedly questionable correlation but I include it as a curiosity that you would never see in the anti-psychiatry American press:

  4. I wish we could do what the Swiss do but I think the horse has left the barn on CMS and its approach to mental health. It will be a two tiered system. By the way, it is over there too, but the bottom tier isn't horrible.

  5. I forgot to add that the Swiss have 3 times as many psychiatrists and we have 30 times as many administrators (rough estimate). That is what happens when businessmen ration healthcare based on their dream of doing it without physicians.

  6. Unfortunately the only road to destroying health care inflation will involve unemployment of many medical middlemen. I will not shed a tear. They will not go down without without a fight though. Wish that energy were directed productively.

  7. Ignore the misleading headline but the chart is important:

    It's obvious what has to be cut to reduce costs in American medicine.

    1. That is excellent data if it is really physician salaries only.

      The usual discussion is that the salaries of American physicians is 30% higher than the next closest OECD countries with a qualifier about the high cost of medical school. At some point the rationing initiative has probably resulted in absurdly higher "productivity" at an undetermined quality cost that results in fewer physicians covering more people. The ratio of Swiss psychiatrists to American psychiatrists is a good example.

      Real numbers of total salaries of administrators and that growth would be equally interesting. My speculation is that there would be an absurd level of growth of administration in the US.

  8. This is the one often cited. I'd like to see what the next seven years after 2009 look like, though I think I know the answer: