Clinical Medicine, Capitalism and Creative Destruction

As the second world war ended, The Great Atlantic and Pacific Tea Company was opening supermarkets all over the country.  In time, local neighborhood grocery stores, bakeries and meat markets disappeared. When WalMart, Kmart and Target saw the opportunity, they began to compete for the family food dollar and eclipsed the A&P.  At the same time, small family farms were absorbed by large produce packaging companies.  They amassed huge tracts of land and adopted industrial scale methods of production.  Frank Perdue became a celebrity.


After that war, the automobile became a global product.  Newly established brands from Europe and Japan entered the American market.  Ford, General Motors and Chrysler survived and lesser marques like Nash, Hudson, Packard and Studebaker went the way of the corner grocer.  Lee Iacocca became a celebrity.


These are examples of the concept characterized as creative destruction.  It was inevitable that this model for change would come to the practice of medicine.  Over the last 20 years, the cottage industry of clinical medicine has been transformed into a collection of corporate behemoths.  In the process, Drs. Gupta, Chopra and Oz have become celebrities.


UnitedHealth Group Incorporated recently acquired the operations of a major physician's organization in California.  The purchase of the management arm of an association of approximately 2,300 physicians in a range of specialties established UnitedHealth's Optum Health Services platform as a formidable presence in the region.  Optum had previously taken over two smaller groups in southern California - AppleCare Medical Group and Memorial HealthCare.  This is the latest example of how lines are blurring between insurance companies and health care providers.


There is no way anyone could confuse the operating principles of such large corporate organizations with the insignia of the single practitioner or small groups of practicing physicians. The days are gone when a physician could move to a community, open an office, hire staff, and build a practice.  It is much too complicated today.  New legislation requires expensive technology, electronic medical records and structured human resources.  In order to deal with all the new rules and regulations, an affiliation with a large management organization is practically mandatory.  All over the country, individual physicians and groups are signing up with area hospitals, medical centers and academic teaching institutions.  As they recruit and buy practices, these large, multimillion dollar institutions with multibillion dollar budgets have made it possible for physicians to affiliate without having to move their office, change their staff or even change their telephone number.


These changes have not escaped the attention of doctors.  When I was in training, it was understood that a physician in practice had to deal with the demands of running a small business.  Although these issues were never mentioned in medical school or during house staff training, I knew there would be some relationship between my overhead costs and take home pay.  As more and more physicians realized that they weren't going to be just practicing medicine but would be part of a health care industry, they decided a Master of Business Administration degree was the appropriate credential.  By the late 1990s, there were a half dozen joint MD/MBA degree programs in the country.  Today, 65 institutions offer the combined degree program - with tuition and fees amounting to more than $250,000.  Not a trivial investment!  And, more significantly, not time spent acquiring or mastering skills sets relevant to caring for the sick!


Perhaps the most striking feature of the corporatizing of medicine is the widespread use of advertising campaigns by doctors and hospitals in newspapers, magazines and on television with the objective of increasing their market share.  It's not possible to estimate the total spent for advertising, however, it is clearly a significant addition to the cost of business.  Prestigious institutions such as New York Presbyterian, Johns Hopkins, Baylor, Cleveland Clinic and Cedars-Sinai have all launched costly promotions to extend their brand beyond the logical perimeter of their customary catchment area.  So Johns Hopkins Hospital is spending money to recruit patients to Baltimore from New York City - competing on New York Presbyterian Medical Center's turf.  It's said only one half of the dollars spent on advertising really works.  Since advertising is such a large part of the nation's health care budget, a great deal of money could be saved if we knew which half that is.


When entering the medical maze today, the odds of finding a solo medical practitioner or one in a small group are about the same as sighting a Packard on the interstate.

What this is all about....

I am a retired surgeon.  Do I miss the practice of medicine?  I miss something that doesn't exist anymore.  What we have now is Corporate Medicine.  Think about it....if you are a pregnant woman today in urban America, you have less than a 50% chance your baby will be delivered by your obstetrician; if you are about to undergo an operation on your heart - lung - intestine - bladder - ovary - you have approximately a 0% chance of having your stitches removed by your surgeon. If you are hospitalized, there is a very good chance you will be cared for by a hospitalist.  Hospitalists are physicians employed by hospitals. They frequently work 12-hour shifts and are often limited by local regulation to three 12 hour shifts a week.  This means it will take 5 different doctors to cover the 14 shifts in a 7 day period. Think of the chances for confusion and misinterpretation of information as the patient is handed off from one physician to another.  Shift mentality has also taken over the practice of out patient medical care.  Call your doctor after 5pm or at the weekend or on a holiday - the chances your call will be returned by your doctor are estimated to be on average less than 1 in 4!  This is corporate medicine at work - the managed care organization; the physician organization; the hospital-run organization; all balancing the clinical and financial aspects of medicine, and not necessarily for the patient's advantage.

The cottage industry of medical practice, where the doctor-patient relationship was the cornerstone of the medical care establishment, no longer exists.  Health care - formerly know as medical care - is now a technologically complex sector of our economy accounting for close to 20% of our GDP.  The explosive growth of the health care industry - with diagnostic testing that can cost thousands of dollars, procedures that can cost tens of thousands of dollars, and courses of medications costing hundreds of thousands of dollars - has severely compromised and undermined the integrity of the doctor-patient relationship.

The claim that we have the best medical care system in the world is not surprising - we spend more per capita on medical care than any other country.  While it is true there is the potential to get the best care in the world here, for a significant number of Americans this care is not available or accessible.  Our infant and maternal mortality rates are not even close to the top of the list among nations    
                                           http://www.globalhealthfacts.org/;   
and an investigation carried out by the Hearst media corporation in 2009 reported there were about 200,000 deaths attributable to preventable medical mistakes and infections  http://www.scientificamerican.com. These are just two indices of less than best care.

The primary policy driver for medical insurance companies is cost.  I have read the Affordable Care Act, commonly referred to as Obamacare, and I am concerned that a mechanism for extending that same bottom-line consideration will be inserted into government funded medical care under the guise of quality of life indices.  These practices have yet to be defined, but many members of congress have not even read this legislation or examined its intended and potential unintended consequences.

My point is that the practice of medicine has been contaminated by policies that are not in the patient's best interest.  There are good - better - best approaches to the care of the sick.  I am going to write about what you can do to ensure you find the right provider, learn what your options are, and select the appropriate approach to get the best outcome when you have to deal with our health care system; as well as major issues confronting our health care system today.