As a country, we are at a crossroads.
We are in the middle of trying to figure out a lot of things, from climate
change to reproductive rights to health care. I’m certainly not an expert on
everything, but I have lived through significant changes in the healthcare
system, and I believe it’s important we all understand how we got here…and
where “here” is. To put it all in perspective, I’d like to give you a peek into
what healthcare used to look like. Perhaps you remember.
My grandfather was a family
practitioner, and did everything from setting broken bones to delivering
babies. He saw the patients, and my grandmother sat at the kitchen table with
the accounting book spread across it, with all the bills piled up. She logged
in the names and accounts receivable of all the patients my grandfather saw
that day. It was a true family business. The office was connected to the house,
so it was my playground, and I easily flowed between the smell of chicken
vegetable soup in the kitchen to antiseptic in the office, depending on which
side of the house I was in.
I loved it. I loved the
patients who were coming in and out, and the grateful look on their faces when
my grandfather helped them. I loved knowing he was caring for so many, bringing
life into the world, and sometimes helping the elderly simply grow old with
dignity and vitality. He cared. He was smart. He was his own boss, with his own
rules, with ethics and morals and a point of purpose that drove his days. My
grandmother was the same, with a razor-sharp brain for numbers and business,
having run her immigrant father’s store when she was a young girl, doing the
books by the age of 13. There was a purpose to both their lives, and it was a
simple one: Taking care of people and their families. Growing up this way is
what made me decide to become a doctor.
When I was in my training, I
remember the day I found out that the hospital I was training in was joining
another hospital, and that, in fact, there were going to be three hospitals
coming together to create a “system,” to be run under one umbrella. Ignorantly,
I thought, ”How cool!” I thought it would be awesome to collaborate with other
doctors. I even started a virtual women’s program, working with other women
cardiologists throughout the system so we could all come together in support,
share our resources, and help people together. I do remember that some of the more
senior doctors were anxious or angry, but I didn’t know why. Ignorance is
bliss, I suppose, but it was this ignorance that has, in part, led to the
predicament we are in now.
Recently, I read a book by Dr. Elisabeth Rosenthal explaining what I was about to live through. It’s called An American Sickness: How Healthcare Became Big Business and How You Can Take It Back. This book eloquently explains how and why there was a clear “then” and “now” when it comes to healthcare. As I read it, the memories came flooding back, and with Dr. Rosenthal’s insight, what was happening to me—and all doctors—has become even more apparent.
You see, unbeknownst to the
doctors, in the late 1980’s the business of medicine was well underway, and by
the time I graduated from training in the early 2000s, the hospital system had
become a multi-layered business driven by the bottom line. As Dr. Rosenthal
states in her book, “The cost of hospital services has grown faster than costs
in other parts of our healthcare system.” She writes that about 80% of patients
under the age of 65 years old were covered by good insurance between 1968 and
1980, so hospitals pushed the envelope, billed the insurance companies, and the
insurance companies would reimburse at these high rates.
Essentially, hospitals were
gaming the system, and that changed everything. They began to morph from
caretaking facilities to money makers that were then forced to hire
administrators to figure out the bottom line. Professional coders who understood
the insurance lingo were brought in to figure out how to bill to get even more
financial reimbursement, and doctors were trained how to write their notes to
code for higher reimbursement rates, too. They were instructed on what
procedures to perform more often and in what order, to make sure that hospitals
received the maximum revenue.
But many of us didn’t realize this was happening. Even into the 90s, in many academic institutions, the essence of medicine (caring for patients) was not yet lost. The clinic I worked in was staffed with doctors in training and there was strict oversight by our academic doctors, training us to be the best we could be. This was the era of the HMO, and costs were relatively contained. In fact, this was the only decade since the 1940s when US health spending did not increase faster than the cost of living. Unfortunately, however, many of the HMOs were poorly managed and besides Kaiser Permanente in California, most of them died out (thanks for explaining this one, Dr. Rosenthal!). Being only in training, I could never have known that this was the calm before the storm. Things seemed to make sense then. At least, at that time, doctors still valued the big picture of healthcare as a way to help people.
But as I was getting ready to
graduate, I remember sensing a shift. I felt it the day my medical license
became a valuable commodity to the system. Suddenly, I went from being a
student to an employee. Billers began to teach me how to maximize the profit
potential of my medical records. They explained coding to me, to ensure that
insurance companies reimbursed at their highest level. Electronic medical
records made this easier by showing us which boxes to check to get more money.
Administrators made it clear that doctors were dispensable employees who worked
for a system to create revenue. Our personal value to the institution was less
important than the bottom line of the business. The once-revered position of
the Chief Medical Officer of the hospital morphed from being awarded to the
most skilled, experienced physician, to a position given to the doctor who was
best able to make sure the hospital doctors were financially rewarding to the
system.
Today, most every hospital is
driven by administrators and consultants, and the terms “strategic alliance,”
“the bottom line,” and “reimbursement” have become standard hospital speak.
Doctors’ value is now determined by their financial value—now they call it
their RVU, or “relative value units.” This is a measure of productivity, and a
means to determine medical billing and how much financial productivity a doctor
is creating for the hospital.
Around the year 2000 (I
graduated in 2002), hospitals decided they would no longer pay physicians a
fixed salary and they would determine their pay by these RVUs. This really
changed the game because if doctors became incentivized to see more patients
and do more procedures that would then get reimbursed at a higher rate. The
actual care of patients wasn’t (and really, could no longer be) the priority of
hospitals or their doctors because everything was centered around and
driven by financial gain. What really happened is that doctors lost their
power, becoming mere cogs in the wheel of the hospital system. What could we
do? Doctors are caretakers, academics, and interested in patients and health.
Very few were willing or able to fight back or knew the business of healthcare
enough to even know where to begin.
It’s been almost 20 years that
I’ve been in the system, as a trainee and then as a physician. I “ran” programs
and in my naivete believed I could make a difference and have an impact. It
wasn’t until an administrator from my recent position made it clear to me that
my value was based solely on my financial benefit to the system that I paused
to learn more. I needed to understand why having an impact on women’s heart
health was not significant. I did research, and I expanded my own education
beyond what was told to me in the
system by the system.
At the beginning of this new decade, I left the hospital, opened my own office, and researched reimbursements and how I wanted to take care of my patients. I decided 15 minutes was too short for a thorough appointment with a patient, and an hour seemed right. I decided I wanted my staff to feel valued and appreciated. I wanted my patients to know how much I honor their trust and how much I value our relationship. I wanted to go back to the days when my grandma just wrote down the accounts receivable for the day for the true heart-driven work my grandfather put in on behalf of his patients.
I
can’t go back in time, of course, but maybe I can set an example for a future
of health care that values the patient again. For the first time, I feel like I
am on the right track to making an impact and changing healthcare. I am no
longer a cog in the wheel. I am taking care of patients the way we all deserve
to be cared for: with passion, with purpose, with research, and most
importantly, with my heart.
Click here to buy Dr. Suzanne Steinbaum’s book, Dr. Suzanne Steinbaum’s Heart Book: Every Woman’s Guide to a Heart-Healthy Life
