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.

Ref:

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.

Ref:

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).

An Excursion into the Psychiatric News - Blurred Lines Between Business and Professional Organizations

Psychiatry Eclipsed

Before anyone says that this is me going off the rails again - consider one small factor.  For over 30 years I have been paying the American Psychiatric Association (APA) significant amounts of money in annual dues.  Last year it was about $935.  During some of those years, I thought it might be useful to also donate to their political action committee and I gave them significantly more money.  All the time, I was expecting something to reverse the inexorable deterioration in the practice environment  and the rationing of mental health services.  During that time, I witnessed first hand the deterioration of psychiatric services in the state of Minnesota to the point that there is now a mandate that county sheriffs have priority in admitting their mentally ill prisoners to state psychiatric hospitals.  The psychiatrists in the state have no say in who gets admitted to these facilities or the severely rationed number of inpatient beds in the state.  The reason for professional organizations as I understand them is to speak for and advance the profession, support its members and advocate policies that benefit the people that interact with the profession.  In the case of psychiatry that is the patients that we treat, their families, and the larger society.  All I have to do is pick up a copy of the Psychiatric News to doubt that these mandates are very relevant anymore.

I will say in advance that in my assessment the APA does a fair job in terms of education and professionalism.  I have criticized them in this area in the past for not keeping the treatment guidelines up to date and relevant.  Subsequent to that there was a new guideline published.  Access to the educational materials is not contained in the membership dues.  A subscription to Psychiatry Online or the CME Journal Focus are additional charges as are CME credits for reading articles in the American Journal of Psychiatry.  There is also a CD version of courses and presentations at the APA Annual Meeting that is available for a significant cost.  The educational and professional materials are definitely available and some of them are first rate - but they do come at a price.

My biggest problem with the APA has been the total lack of rigor in countering the deterioration of the practice environment and in many cases seeming to directly participate in initiatives that are counter to the interests of psychiatrists and their patients.  Thumbing through the September 16, 2016 edition of the Psychiatric News provides some ready examples.

On page 1, there is a story Everett Appointed head of New SAMHSA Office.  The story is all about APA President Elect Anita Everett, MD assuming a new position as chief medical officer at SAMHSA - the lead federal agency for mental health and substance use treatment.  A direct quote from Dr. Everett: "Having a psychiatrist as a member of the leadership team at SAMHSA will enable psychiatrists to join other mental health and public health professionals in guiding the federal component of the nation's behavioral health systems."  My emphasis on behavioral health.  As far as I am concerned SAMHSA is a pro-managed care government bureaucracy - like most of them.  Secondly, there are plenty of psychiatrists out there who have been chief medical officers for managed care companies and I would challenge anyone to tell me why they are necessary and what they have accomplished.  Managed care companies tell psychiatrists what to do.  They are not interested in a reasonable practice environment, reasonable inpatient settings of even professional standards.  They are interested in cheap, rationed care by overworked clinicians.  I don't doubt Dr. Everett's qualifications or good intentions.  I don't think I am going out on a limb too far to say that she is going to be severely restricted by the current bureaucracy with a strong managed care bias.  That is not good for psychiatrists and it certainly is not good for patients.

The other story on page 1 seems worse - Are Psychiatrists prepared for Health Care Reform?  Yes and No.   I really can't think of a more nauseating term in the medical literature than health care reform.  I have been hearing those hot little words for the entire length of my career.  I heard them from the Clintons back in the days when Hillary Clinton headed up the health care reform efforts during the first Clinton presidency.  Some students of the topic like to recall that for one reason or another the initiative worked on by Hillary Clinton was not successful.  I think that depends on the standard.  There certainly was no expected global program, but it did make managed care a household word and set managed care as the predominant bias in all further discussions of health care reform.  Like most history - people seem to have forgotten this and the Clinton administration (and all that followed) as having a strong managed care bias.  The article suggests that psychiatrists need to get on board with the collaborative care model - another managed care rationing technique.  In the span of 3 decades psychiatry has gone from protesting managed care rationing (especially because it affects us and our patients the most) to suggesting you really have to get on board with this.  The usual buzzwords like further workforce development and merit-based payment reforms are evident.  When professional standards are abandoned what is merit-based payment reform? In all likelihood it has to do with rationing techniques rather than quality medical care.  Paragraph after paragraph in this article read like a managed care playbook.  Maybe the only way to see through all of this pro management rhetoric is to have actually worked in one of these systems of care.  Try working in one with a manager who is reimbursed to extract the maximum amount of productivity while not providing resources to physicians in the system.  In that case I believe the management buzz word is creativity.  In a rationed environment there is often an audacious statement about creativity as a solution rather than additional personnel.  Most reasonable people would be shocked at what constitutes merit-based payment or the hold back procedures before you can get to that level.  Just another in a long line of meaningless cliches flowing from health care reform.

As you might imagine I was a little tense and clammy as I went on to page 2.  There I was an editorial piece by APA President Maria A. Oquendo, MD.  It was title Why 'Physician Heal Thyself' Does Not Work.  I was mildly optimistic that she might come to the same conclusion that I have about physician burnout - it is not a disease it is just bad management.  Dr. Oquendo began  with a description of the recent suicides of a psychiatric resident and a medical student.  She presents the epidemiology of physician suicide and suicidal ideation.  She points out for example that suicide is the second leading cause of death for physicians between the ages of 24 and 35.  She discusses the stigma of a psychiatric diagnosis and the gap between problems and who gets treated.  Her solution is self identification of depression and excessive alcohol use.  There seem to be other factors that are operative.  She quotes a six fold jump in PHQ-9 scores during internship - using that as a metric for depression.  I can't help but think how physicians and trainees are more isolated now than ever.  No matter what the setting we had great teams when I was an intern and resident.  We took care of one another and we had attending physicians who cared.  I addressed some of that in my previous burnout article.  Nobody discusses what it is like to train in a managed care and rationed environment today compared with medical care as usual in the past.  During my last stint in a hospital I did not see well developed teams anywhere.  Most of the senior physicians who did a lot of the teaching and tended to view themselves as affiliated with residents had been replaced by hospitalists.  Entire teaching services had been replaced.  Non-medical management has left many medical institutions very arid places with few personnel and limited collegiality.  That is exactly the wrong environment for depressed and stressed physicians.   Training programs everywhere can help residents by making sure they build collegiality and that team factor in all of their rotations.  They need to provide highly motivated faculty who have the interests of trainees in mind as a priority.  The teams I am referring to here are teams of physicians, not teams that contain administrative staff telling physicians what to do.

The article most directly related to managed care hegemony was "Medical Necessity in Psychiatry: Whose Definition Is It Anyway? by Daniel Knoepflmacher, MD.  The title is of course purely rhetorical.  Like many things in medicine today medical necessity has nothing to do with medicine.  It is a pure business definition designed to give the appearance of legitimacy to what is a pure business driven decision.  The decisions are made by people with no appreciation of human biology or its complexity.  They are people who seem to think that a lot of meaningless business metrics somehow apply to the practice of medicine.  At the worst (and most probable) they are simply rationing to make a profit.  I would call them nerds but I really don't think that they are that smart.

In the article, Dr. Knoepflmacher makes that point.  There is not even a standard business definition of medical necessity.  Companies can basically say and do whatever they want.  He traces the history of the term and how various groups define it today.  Interestingly one of the largest managed care companies states that it is for payment purposes only.  He points out the overemphasis on acute or crisis care rather than professional guidelines or standards.  I would argue that in psychiatry, managed care companies do a very poor job of addressing acute care by using only a dangerousness metric.  The term cost effectiveness is incorporated into some of the definitions in the 1960s.  The acclaimed Mental Health Parity and Addiction Equity Act of 2008 lacks any definition of medical necessity or a more useful definition of medical appropriateness.  That may explain why this legislation has had negligible impact.  Dr. Knoepflmacher's thesis can be best summarized in the sentence:

"Without universal medical necessity criteria for mental health care, clinicians and their patients are saddled with a concept highly susceptible to abuse by insurers."

I would take it a step further.  The abuse has been institutionalized at this point.  Clinicians find themselves abused at every fork in the road.  Any time a psychiatrist refills a medication for a colleague or because the treatment setting has changed they are subjected to abusive prior authorization processes that are in place purely to harass physicians into giving up and patients to the point that they are paying out of pocket instead of using the insurance they have paid for.   In that case Congress is directly responsible for erecting two multibillion dollar industries and inserting them between the physician and their patient.  I would also propose a much better limit than arbitrary medical necessity criteria.  It should be apparent that any managed care company can get around legislation and rules that they lobbied to pass.  I propose that physicians recommend a course of treatment to patients and that they are totally removed from the payment process.  No more wasting time with insurance company employee-reviewers.  No more conflict of interest in favor of big business.  The physician recommends treatment.  The insurance company tells the patient if they will pay for it.  Other than civil action by the patient, the only oversight should be a panel of physicians carefully screened for conflict of interest at the state level to mediate disputes (sorry no insurance industry insiders).

Highlighting these four articles creates a portrait of what is wrong with the APA.  Like other professional organizations it has clearly bought into the pro-management zeitgeist that is generally sold by American businesses and government.  The general idea is that there are business managers that know more about what you do and can tell you what to do - irrespective of your professional training and experience.  That idea is a mile wide and an inch deep.  Anyone with middle school analytic skills should have come to the same conclusion as Dr. Knoepflmacher - about 20 years ago.  His article is there now as a necessary reminder that there is a much better way to do things.  Instead of affiliating with these outrageous business practices - they should be actively resisted at every level.  That should include the practice and training environments.  There is nothing worse for physicians and patients than wringing the humanity out of medical practice.

And there is nobody better at doing that than current healthcare business managers.


George Dawson, MD, DFAPA



Attributions:  The graphic is all me.  It is supposed to represent a progressive overlap by government and business interests with the profession.  There are psychiatrists that work in the overlap areas and some who work just in the black and gray zones.  The field is still plodding along as though it is an autonomous profession.  

Modern Medical Management - The Myth of Sharing

Any casual reader of this blog will note that I don't really find any value in the myriad of management practices that have been added to medicine since businessmen and their friends in government have taken over.  The only reasons that these practices have been added is strictly political and rhetorical.  Nothing has been overhyped as much as management adding value to medicine with so few results.  Nothing has done quite as much to detract from the quality of care than these same business practices.  At this point they have become as entrenched as gun legislation and will be every bit as intractable. These problems are very difficult for the typical consumer/patient to see.  The obvious points of contention are insurance company denials either for medication or medical care.  They peaked in the 1990s when managed care companies thought that they would just put specialists out of business and had primary care physicians acting as "gatekeepers".  If you are old enough you may recall having to get a referral from your primary care physician to see specialists, for various services. and in some cases even to go into an emergency department.  It took them a while but these businesses learned that being that transparent in denying care was probably not in their best interest.  It also created a large burden on primary care physicians who were now uncompensated reviewers for the insurance company business practcies.  Eventually that system was scrapped in favor of shifting financial risk around - some to consumers and some to physicians and physician groups.  There are many ways it can happen, I thought I would provide a few examples below.

Managers like to use a shared decision making model in their manipulation of physicians.  I guess they don't consider physicians to be particularly bright people.  I don't know if that happens when you are socialized in the business world and automatically consider your decisions to be the best based on scant data, a lack of measurement standards and perceived quality of a good idea.  Whatever the reason, the approach generally only works because the physicians have no leverage.  Consider the following example.  Ten physicians are in a group providing hospital coverage for admissions to a community hospital.  It can be any specialty.  They are working a 7 days on and 7 days off model and each of them typically admits 10-14 patients per day at work.  They are stretched to the maximum so that anyone requiring emergency leave seriously disrupts the schedule.  Their colleagues are expected to cover.   The administration would like to open an 10% additional bed capacity and meets with all of the physicians about this to problem solve over how that might happen.  The physicians are asked the question: "We are here to all figure out how to increase the number of admissions by 10%.  Do you have any ideas about that?"  That leads to a general discussion of how the physicians are overworked and already spending too much time from home on the electronic health record.  A consensus builds and the physicians say they need more staff and staff to cover unpredicted absences.  At that point the administrator states: "No - I guess I didn't explain myself very well.  We are here to decide how to provide more services without increasing the cost by hiring new people."  The physicians finally get it.  Sharing in this case means, I will ask you for your input, but it is meaningless and I will require that you work harder even though you are probably burned out right now.

Another popular sharing model where physicians share more than anybody else is financial risk sharing.  The first introduction was when RVU productivity units were introduced.  The initial administrative argument seemed to be that not everyone was carrying their own weight.  The RVU system was portrayed as being inherently more advantageous to those people who were really productive.  It would allow them to make more more than the slackers in the department.  That was a good theory to try to appeal to physicians competitive natures, but in most departments - schedules and productivity was already saturated.  There were no slackers.  That point goes to the administrators.  The second risk sharing introduced was the "holdback" model.  This said that 10-15% of everyones' productivity would be held back until it could be assured that the production figures were met and then it would be released to the physicians in the group.  Keep in mind this was money that was already billed and earned.  There was no similar "holdback" from administrators or other personnel.  A take off on this risk sharing was getting physicians in administrative meetings and showing them endless spreadsheets of overhead costs and how much they would have to "produce" in order to get either their holdback or some other form of reimbursement.

The ultimate form of risk sharing today seems to be the contract that comes in and puts everyone at risk by not even recognizing the physician billing.  In this case the insurer comes in and says - this is how much we will pay you on a per diem basis to cover these patients for various problems.  You agree not to charge use anymore than than - no matter how much care each one of those patients needs.  This last model is the most insidious.  It caps any insurance payments (losses) and puts any physicians and their clinic at complete risk for catastrophic loss but more importantly it is a war of attrition.  With this model as the only source of funding, it allows administrators to view physicians as "costs" rather than resources and eliminate them, underfund them, overwork them, and burn them out.  It is a tried and true pathway for how managed care organizations using this model can adversely impact the quality of care in every organization they contract with, but especially the ones that don't understand corporate doublespeak.

Too many of my colleagues tolerate corporate doublespeak in management systems.  They don't seem to understand that risk sharing does not really mean that anything is shared.  It means that they are left holding the bag.  These same systems tell us how "younger physicians" are more accepting of these models.  Medical professional organizations and specialty boards are talking the talk.  We have the American Psychiatric Association talking about various collaborative care models where psychiatrists don't need to see patients any more.  The speciality boards have designed a number of expensive and complicated performance metrics that have no basis in reality and CMS (Centers for Medicare and Medicaid Services) has done the same.  It is hard to imagine that when I started out in Medicine we did not have to deal with all of this administrative fantasy.  We went to work each day and it centered on the facts, patient care, and the medical science of the day -

Not what somebody forced us to believe for a few months at a time while they were wasting our time, energy, and money.

  

George Dawson, MD, DFAPA