I was buoyed to see this line as the title of a financial blog today: "Coming Corporate Control of Medicine Will Throw Patients Under the Bus". You don't usually see that level of insight into what is going on in medicine from financial people who have usually bought the "cost effectiveness" dogma, even at a time where middlemen are siphoning off hundreds of billions of dollars from the direct provision of health care and producing an inferior product. I will say it for the thousandth time - what other industry can make money by selling you a rationed product and denying your access to that product? Can you imagine what the automobile or cell phone market would look like with that guiding principle?
The article is focused on two critical issues-physician management by people with no medical experience and the message from the top. The first part of the article discusses the situation of a pediatrician who had successfully managed a clinic but found herself being managed by a non-physician who told her that she either had to see very complex patients in a shorter period of time or not see them at all. The second part of the article focuses on a blog post where a CEO/physician for a managed care company flat out encourages physicians to get rid of difficult patients to improve their managed care style performance measures.
The blogger in this case is Yves Smith. I have been reading her blog for years. She wrote the book Econned and takes a generally skeptical view of that way that financial markets are regulated and run. I have seen her do commentary on some financial television but infrequently. I would tend to see her commentary as legitimate criticism and welcome in the area of physician and health care management. As a blogger she is highly successful. This post alone has about 40 pages of commentary.
In this article she has some additional comments about what physicians face in the assembly line of today's managed care environment:
"As an aside, it's hard to stress enough that this sort of demoralizing micromanagement an unwillingness to listen and learn from workers is a weird shortcoming of management American style. And it has been weirdly airbrushed out of the media."
I can't agree more with the second comment in particular. The American public gets a glimpse of how their health care management occurs only when Michael Moore makes a movie about it or they are confronted face to face with an impossible situation. That happens all of the time in psychiatry with restrictions on treatment to the point that it seems like treatment has never occurred. To get that accomplished takes both micromanagement of physicians and a general management style that greatly emphasizes profit margin over patients. At the public relations level, physician opinion especially physician dissent is not tolerated. The personal experience of the physicians in these systems is considered the property of the organization. Any public disclosure of the severe shortcomings can be ruthlessly suppressed either by firing or a series of political maneuvers designed to force resignation at some point.
There is a divergence of medical and corporate culture at the level of disclosure of errors or wrongdoing. For most of my professional life I have been in monthly conferences - some type of mortality-morbidity conferences where real or potential errors were discussed on a department wide basis. I don't think that happens in the corporate world. I think that errors in the corporate world are acknowledged if they are widely known and there is an emphasis on public relations and maintaining an almost unrealistic positive light on the company. That has been most evident in the past decade with an abundance of managed care public relations. Wherever I turn it seems like I come across a hospital or clinic that is proclaiming themselves as the "best" - usually in the country. That kind of advertising by physicians was widely viewed as unethical by state medical boards. These ratings are usually based on a few process parameters that can be actively "managed". Contrary to what health care management tells you the quality of any hospital or clinic depends on the quality of the physicians working there and the level of autonomy they have in their medical decision making.
You can have the best surgeons, internists, or psychiatrists in the world and if they are managed to see as many patients as possible and provide the care that will provide the best profit margin for the company - their medical and surgical care will not be appreciably different from a mediocre staff.
I wrote a piece several years ago about an informed approach to managing knowledge workers that originated with management guru Peter Drucker. The details can be found in the original piece in this newsletter (page 3) and a earlier posts on this blog. Everywhere I look in health care we are at the opposite pole from Drucker. Managers are generally far too authoritarian in dealing with physicians especially in cases where (like the Yves Smith blog post) - the mangers know far less than the physicians. This managerial style is also disruptive. Many health care managers think that they can implement any idea they wake up with that morning if they accompany it with enough "Change is good" or "Cost effective" rhetoric. All of this micromanagement and mismanagement illustrates that Dilbert has changed professions. He is currently wearing a white lab coat.
The other bad news of course is that corporate control of medicine is not coming - it has been here for years. In the case of psychiatry it has been here for 30 years. Anyone who wants to see how corporate control of medicine changes things only has to look at the state of current psychiatric services or their "shortage" for a lesson.
George Dawson, MD, DFAPA