The commoditization of doctors is a pattern both insidious and distressing. Examining reimbursement and medical practitioner nomenclature trends over the past few decades, one can see with certainty that doctors have been branded commodities; we are no longer individuals possessing unique qualities and skillsets. In the minds of insurers and patients all doctors are created equal. We are considered interchangeable, like nails for a rooftop or cement for a slab. Until reading the November 24th issue of the NEJM, I was under the naïve misapprehension that in the eyes of other physicians we were still understood to be more than just assembly-line products. Now I know otherwise.
In the “Perspective” piece by Dafny et al, the case is made that the government and insurers must ensure that under the evolving healthcare reimbursement system, doctors do not mimic the moneymaking tactics of pharmaceutical companies. Apparently co-pay cards and other techniques have served to bolster brand, as opposed to generic drugs. The authors find this loophole to be flawed; after all they assert, generics are precisely the same as brand drugs. (This is certainly apocryphal, the anti-epileptic medications being the best such example.) But more revealing than their flawed understanding of this element of ‘non-medical switching’ is the simple fact that the authors warn insurers to be on the lookout for doctors’ attempts to circumvent the approaching “value based” reimbursement system. Their admonition impugns doctors’ integrities, implying an inappropriate desire to be compensated for our hard-earned skills. Unfortunately, the definition of “value” is too complex to explore here; yet, one should note that it hinges largely on saving money. Yes, quality is loosely woven into the framework but money is truly the construct’s foundation.
Dafny et al also praise The Accountable Care Organization (ACO), the system that will ostensibly create higher quality medicine while concomitantly lowering doctors’ fees and overall healthcare costs. Regrettably ACO costs are lowered through negotiations; doctors will accept reduced fees in order to gain contracts for more “lives” – otherwise known as “patients.” So will this in any way engender better care? The answer is of course, no. Treating more patients in shorter time frames never results in improved care. Though quality as I mentioned is thrown into the equation, it plays but a small part. Also, it turns out that quality is not such an easy metric to ascertain. Ironically, as per Khot et al from the Cleveland Clinic, patients’ perceptions of medical quality is typically inversely related to outcomes: the higher the perceived quality, the worse the outcomes. Additionally, doctors and hospitals have notoriously avoided caring for complex patients in order to guarantee better statistical outcomes. With a clear monetarily based bias against caring for them, the sickest patients lose the most.
So before everyone jumps on this runaway bandwagon, let’s enjoy a moment of circumspection. Ask yourself two simple questions: Does the hatchling doctor possess the same skillset as a seasoned physician with decades of learning and experience? And, would you prefer being operated on by someone fresh out of training or would you chose a surgeon with thousands of “cases” under his/her belt? The answers are clear – experience counts. So why in medicine are experience and reimbursement disconnected? Recently I employed three attorneys possessing diverse skillsets and experience. While the most seasoned one earned $600/hour, the novice earned $250. In every other profession or business, experience translates into superior remuneration. Medicine is the only job, including the priesthood, in which we are all considered to be interchangeable. This commodity concept is absurd, and until the powers that be recognize and extinguish this false narrative American Medicine will continue to speed down the very steep and rocky slope of deterioration.