I’ve decided that I’m not finished with Karen Regier (see my previous blog, “Medical Economic Cretinism”). Remember her ultimate blunder: “Direct employment (of physicians) is beneficial because it provides greater collaboration in the delivery of care…..” Not to beat a dead horse, but there’s so much more that needs to be said in response to this.
A friend of mine had surgery at a local hospital recently. His surgery was done by a physician who “collaborates” with a hospital. The benefit of this “collaboration” follows. You see, this friend of mine is perfectly healthy. The procedure he was having done was a minor procedure. He went to pre-register for his surgery the day before at the hospital and was sent to the lab. There he was told that he would need an EKG and blood drawn. He called the anesthesiologist who was doing his anesthesia the next day to ask if he wanted all of this lab work. “No.” “That’s not needed.” He called the surgeon’s office to ask if this was something they wanted. “No.” “But the hospital requires it and there’s nothing I can do about it.” Is it possible that this “not for profit” hospital in collaboration with physicians they control or employ is racking up lab charges that are completely unnecessary? Is this an example of the “beneficial collaboration” that Ms. Regier is referring to in making her case for hospital employment of physicians? The money required to pay for this unnecessary lab work multiplied by the large number of patients seen at this facility is a staggering amount and a complete waste. Beneficial collaboration for the hospital, though.
I made the statement in my previous blog that employed doctors basically don’t care whether they see 15 or 45 patients. They make the same either way if they are on salary. While this is true, there are some hospitals that have modified their employment agreements with physicians because they have found that simple salary payment turns previously hard working physicians into beach bums. These modifications are called various things but essentially amount to performance incentives or bonuses. But wait a minute! If doctors are kind of getting paid for what they do, how is that different from the “fee for service” concept Ms. Regier finds so inefficient? Her argument is not against “fee for service” arrangements as she would have us believe. Her argument is for control of physicians by hospitals. Once the hospitals control the physicians then they can make them order unnecessary lab work I guess.
Once physicians are employed by hospitals, “who is best” no longer applies. I have written prior blogs on how “integrated” doctors (employees of hospitals) receive referrals from other “integrated” doctors, not because they are any good (in many cases they are dangerous and are thought of within the medical community as dangerous, unethical or both) but because they are “integrated,” you know, part of the club, part of the cartel. This is, of course, money -driven by the hospital employers (always seeking to not make a profit). A friend of mine not long ago got trapped in the quicksand of a hospital network and wound up in the office of a notoriously incompetent surgeon who recommended immediate emergency surgery. My friend called me and after hearing who they had seen, I made arrangements to see another surgeon, one who has been shunned by this hospital network, even though he is thought of as one of the pre-eminent surgeons in this entire area of the country. He told my friend that they didn’t need surgery at all, did a simple office procedure, placed them on antibiotics and that was that. The surgery that the “collaborator” had recommended would have incapacitated my friend for about six weeks and carried a significant risk of life-altering complications. I guess when patients “leak” out to a non-integrated doctor the hospital loses revenue and well we just can’t have that, can we?
Wow! I guess Ms. Regier didn’t know any of this stuff, right? Don’t make me laugh.
G. Keith Smith, M.D.
At a recent meeting, I overheard another surgeon in my specialty who was part of a hospital multi specialty group, speaking with other surgeons about preoperative history and physicals. I was interested because my daughter is treated by a surgeon who is employed by children’s hospital in OKC and has surgery pending in January. My wife told me she has to go back no more than two weeks before surgery for a preop history and physical.
Similarly, the doctor at the meeting said that all his patients must return for a history/physical as well. This is their group’s requirement. I began to wonder if maybe I was not providing appropriate standard of care, since I do all my H and P’s the day of the patient’s visit and again the day of surgery.
Since I have a physician assistant, I thought I would just have her do these a few weeks before my patients’ surgeries. I notified my billing coordinator of the proposed change. She notified me that that was ok, but that we could not bill for the H and P, as this was considered a global part of our surgery fee.
So, as in your above example, both my daughter’s surgeon ( hospital employed) and the surgeon I overheard at the meeting ( mulitispecialty clinic employed) are required to send their surgery patients to primary care doctors in their respective organizations for a service which they can then bill for, since it’s is provided by a physician who is not restricted by the global service restriction.
Therefore, these patients are billed for an additional service that could otherwise be performed at the time of their surgical consult or the day of surgery for free. Certainly, during the H and P visit, the patient will likely receive other “standard of care” preop labs or X-rays that otherwise are unnecessary.
Add that up for all the employed surgeons providing surgical care around the country for some serious “cost savings”!
Comment by Jason sigmon — December 13, 2011 @ 10:09 pm
Great point. Imagine the reaction of your patients if you called them and said I need to see you 2 weeks before your surgery so we can have a fresh history and physical exam so I can bill you for that. Also, I would like to make even more money by ordering unnecessary lab and Xray and you will be expected to pay for that, as well. Your patient would probably fire you or say, “You know, I’ll just see you on the day of surgery!” The presence of this third party billing, at now this unholy alliance between hospitals and their “collaborator” physician employees will run the cost of care up even more and drive the quality down. I have talked with third party administrator executives and insurance company executives that are already aware of this. There is no question that care rendered from the physician who is a hospital employee costs more and your example points this out. Thanks for your always insightful contirubtions to this blog.
G. Keith Smith, M.D.
Comment by surgerycenterok — December 14, 2011 @ 6:22 am