Customer or Patient?

One of the silliest things to happen in medicine in my 10 years of practice is the turning to a business model to improve what we do. Now I am a big free market guy and I believe that competition leads to decreased costs and incresed efficiency. So why would I be against learning from business to improve what we do. I wouldn't be if medicine were a business.

With the advent of medicare/medicaid medicine inched away from being a fee-for-service business to a heavily subsidized and endlessly intricate mystery wrapped in an enigma (apoligies to my hero). Used to be a doctor could hire a secretary and a nurse and open an office and do well if he was good and his patients liked him. Okay, that's business. Now I would challenge anyone to show me this Horatio Alger MD. I know there are boutique practices that cater to those with great insurance or great bank accounts but these are more a curiosity than an alternative to the current system.

As I have stated elsewhere, in the Emergency Department we collect about 30% of what we bill. Recent statistics show that each Emergency Physician in the country gives away about $150,000 in free health care a year. This is because of the unfunded federal mandate called EMTALA, and ED physicians are not the only ones affected. If you are a surgeon, for instance, and you want to practice surgery, then you have to have priveleges at a hospital. This is not true for all surgeons, oral-maxilofacial surgeons can skirt this, but let's just speak about your genergal surgeons, vascular surgeons, chest surgeons, trauma surgeons, neurosurgeons, orthopedic surgeons, hand surgeons, urologic surgeons, gynecologic/obstetric surgeons, and pediatric surgeons. These folks have to take call for the hospital at which they are priveleged. When they are on call EMTALA impacts them too, for if any patient comes into the ED with an emergency surgical condition... appendicitis or an open fracture for instance... that patient is now theirs.

Never mind that with many of these patients the surgeon will not see a red cent for their 3am call to the hospital for emergency surgery. Never mind that they are forced to give hours of their valuable time in these patient's care. Now understand also that these surgeons have practices and have scheduled elective procedures for which they will be reimbursed. Now these reimbused procedures are cancelled for the emergency procedure. No wonder they hate the Emergency Department. I'm not saying, nor would they, that the emergency patient should not receive their operation or should not receive care, I'm simply pointing out that this is not a business model.

It grates on me therefore that the business-minded amonst us are still trying to fit a square peg in a round hole. Believe it or not the administration of most hospitals and ED groups care most about postitive customer feedback (see the prior posts on "Press-Gainey Scores"), and less about good outcomes.

So in medicine, which already resembles a huge ponzi scheme run by the government and insurance companies, the physicians themselves are daily bombarded with ways to improve ''customer service''. Never mind that 70% of our ''customers'' are not paying a dime for their care... they still get to fill out surveys about whether their care was timely and caring. A single angry patient, even one in the country illegally, can get a physician called to the carpet because the physician was ''rude'' or ''didn't explain things'' or a host of other complaints having nothing to do with whether they were treated correctly for their complaint.

Here's another wrinkle, if you are a ''customer'' whose sole purpose is to obtain a prescription for narcotics which you can then use or sell on the street at great profit, and you don't get it because you are proved to be a liar and have 30 prescriptions at the local Walgreens for oxycontin written by different physicians at different facilities within the past year, and you receive a randomly distributed ''survey'' you too can get your treating physician in trouble. Physicians have no counter to this, instead we are treated to lectures on improving our "customer service".

For what purpose? In a fee for service environment where we were truly compteting for dollars that would go elsewhere okay! I get it! When half my salary is going into a deep dark hole anyway why the hell should I care about this? When all our beds are full, the waiting room is full, the hall beds are full, and three patients are dying how am I supposed to give warm fuzzies to the mom who brought in her healthy kid for a ''fever'' that we can't document and a ''rash'' that I can't even see?

Most physicians do not organize, picket, or complain outside their professional circle. We are a beaten bunch. My solution is to never look to see whether a patient has a job or insurance... I treat everyone the same. If I'm not slammed I will hold your hand and explain things to you, if not, you may see me for two minutes. Still, it is painfully obvious many times that the arrogant SOB/DOB who is not sick is in the ED simply because we are ''free'' has no intention of ever paying for their care nor any means to (though they can still afford their cigarettes because 'my husband buys them for me'- no shit!). I challenge anyone to point to another profession where its practitioners are forced by federal law to provide their unique skills for free. Sure, lawyers are expected to do some pro bono work, but they are not required to do so unless their firm demands it.

I challenge you to go to a grocery store, gas station, department store, lawyer's office, mortgage company, or utility company and demand their products or services because you ''have to have them to live'' and see if you get them if you do not pay.

Solution? I don't have a viable one, but I do know that, as I have mentioned before, the country as a whole will eventually get what they pay for. If medicine, perhaps the most intellectually, emotionally, and physically demanding profession that exists, ceases to be attractive to our best and brightest then the quality of our healthcare and physicians (currently at least equal to the best in the world) will plummet. It's not rocket science, if you want to increase use and demand for a sevice then just mandate that it be free.