On the changing relationship between doctor and patient and that element of distrust

Jonathan highlights an Instapundit discussion that caught my eye, too. The discussion is about mammograms and the latest proposed guidelines for screening: do the guidelines represent good science, or are they simply meant to save money (these are not mutually exclusive goals)? I don’t know the science, and don’t have any reason to distrust the health care professionals proposing the guidelines, but I understand that an element of distrust is introduced by the current health care debate.

Anyway, the above linked discussion brings up many interesting points. One is the Public-Health fallacy that Jonathan discusses. Another is the changing relationship between doctor and patient in a system where the federal government intrudes so heavily. Guidelines become suspect. Who is the real beneficiary of the guidelines – the individual patient, or the ‘greater good’ of the population as designated by a government official? The government guidelines, or official, become a third party between the patient and the doctor. The relationship is altered. To some extent, this is already the case with third-party payers and the current level of regulation, but the proposed health care bills take it to another level, entirely.

You see the same phenomenon of distrust when a patient talks about ‘greedy’ doctors and drug companies. I think that distrust will be transferred to Washington under the ‘D.C.-centric’ health-care bills that are being considered. And, in the political fight between constituent groups (patients and others), we may end up with a system where large public health bureaucracies will need to be placated first – a bit like California and the public service unions, or the British NHS*. The entire nature of the doctor-patient relationship will be changed. What do you all think? I’m a physician, and like many physicians, have my own levels of distrust. They are currently being directed at the government takeover of health care.

*I recently watched an old “Yes Minister” (Brit sitcom from the 80s) in which a government minister tries to shut down a hospital with no patients (it has a very large staff). A funny joke, yes? Well, the running joke of the show is that the unions resist by making the following claim – who cares if there are no patients? The greater good is served by all those public sector jobs. So, who “owns” the doctor-patient relationship in that sitcom scenario? Soon, alas, to be ours, perhaps?

Update: Think I used the word distrust enough in the above post? It’s like I’m trying to make a point, or something….
Another Update: Hey, a belated thanks for the link, Instapundit!

26 thoughts on “On the changing relationship between doctor and patient and that element of distrust”

  1. When PSRO (Professional Standards Review Organizations) came out in 1978, we immediately recognized that cost was the criterion for every question. From then on, it was clear that cost issues trumped every other consideration.

    We are the only country in the world with “AM Admissions” before surgery. When this first came up, I asked the obvious question. Why not bring the preop patient into the hospital the afternoon before, as we always had, and just not charge for the time ? After all, they were going to have to add more staff on the early morning shift to deal with all these people coming in at 5 AM for 7:30 AM surgery. Had anybody done a cost analysis on this change ? It just seemed a lot of inconvenience for patients, and some risk, for not very much benefit. Nobody was interested in analyzing the change and it is now established. Whole new areas of the hospitals had to be remodeled, staff added and schedules interrupted when patients show up late or had eaten in spite of instructions. For what ?

    It was amusing to see the change in emphasis for hospitals the day the DRGs went into effect. Suddenly, the hospital was paid a flat fee instead of for each service. Suddenly, we were being asked when our patient could be discharged, often by the same people who, a week before, had been offering new services that would prolong the stay. A couple of years later, the hospital sent out a report on which physicians were “more expensive” and which were “cheaper” for the hospital. Vascular surgeons who had the oldest, sickest patients got the message. If they didn’t, the new Medicare fee schedule that cut payments for complex surgery provided clues. That was 20 years ago.

  2. Well, those guidelines mean that there is yet another element of distrust added to existing.
    As it is, a patient has to critically evaluate everything his doctor suggest: is he saying I don’t need procedure X/medication Y because it’ll not objectively benefit my condition or he’s getting his premium for promoting medication Z/procedure W from a)pharma Co b)insurance Co? As it it, a person has to be of determined character, impervious to White Robe of Authority image, skilled at gathering second (and third, etc) opinions on the net and other sources – in other words, to be in good health and sound mind to be able to make responsible and informed decisions about their own health, which not necessarily coincide with what his doctor tells him.

    So there is not one more factor to evaluate; if there is a conflict between your doctor’s recommendation and what the guideline says, a patient is put into position to decide whose interest runs contrary to his own – the State or the doctor’s. Or both.

  3. Our current ssystem is in the hands not of physicians but of insurance giants.
    Distrust govt/ ask anyone on Medicare if he or she would discard it!
    Please note that under proposed reforms, if you so love your private insurance, then you can keep it..but if you are like those in our congress that prefer single payer, govt backed, then you will be pleased and not have the distrust noted in this post.

  4. A counter trend is taking physicians, especially but not totally, primary care, out of the Medicare/insurance complex. They are just walking away. I put some links up at my blog last summer. The retainer model of primary care practice has the patient pay a monthly or annual “retainer” and all necessary care is provided at that price. This works pretty well for the physicians as 600 patients, at $100/month, can support an internal medicine practice including all expenses. In return, the patient gets e-mail and telephone contact, pretty much at will. The docs can take more time and the old personal model of medical care returns.

    I haven’t spent a lot of time on detail with these doctors on pros and cons but I will note that there is now a continuing education program on how to restructure a practice to cash only. Sermo.com, a physician only site with 110,000 members, has run a survey recently and got over 1800 responses from docs doing this or planning to. If the Democrat plan passes, I expect this to explode. The government plan will be like putting everyone into Medicaid. Private insurance will be frozen in place and will decline. New products will be banned.

    There will have to be an interface between office practice and hospital practice but this has already been created by reimbursement practices now. Interesting times, as they say.

  5. All the doctors and clinics I’ve dealt with lately stink to high heaven. While proclaiming “the patient comes first” they do everything to hide the codes and the costs of every procedure. It took me a solid hour on the phone before I could reach a person at the billing department at MD Anderson in Houston who finally admitted to the fact that they charge some $4500 for a routine colonoscopy for which the Medicare allowance is $193.

    It is at Walmart where the patient comes first. They advertise all their prices (including on the Web), guarantee the lowest price around, offer a month’s supply of a common prescription drug for $4 and charge everybody who walks in their door the same, whether Nancy Pelosi, a sentient Amerikan or an illegal alien.

    Shame on the Medical Profession!

  6. Part of the price problem is that Medicare will not allow honest prices.

    I assume you realize that MD Anderson will not be paid $4500 by Medicare. If MD Anderson lowers its cash price to $193, Medicare will change their profile fee to that amount, then discount it 90%. This is part of the problem with HSAs. Honest prices are not allowed. The doctors who are dropping out of Medicare are adjusting their prices to the real payments they have been getting and lowering their overhead by eliminating the staff that fought with Medicare intermediaries for months and years to get paid. Medicaid in California, when I was still in practice, took about two years to pay and the payment was about 20% of the private payment.

    The HSA user must submit all the claims through the insurance to get the insurance discounted price. That removes the benefit of decreased administrative costs. In fact, the insurance companies that slipstream behind Medicare, firmly resist any attempt to determine real prices as they consider the discounts to be confidential corporate information. My last year in practice, I had 276 contracts with different entities and they all had different payment schedules and requirements for authorization. For example, an HMO once fined me $500 for sending a culture specimen to the “wrong” lab, one down the hall from my San Clemente office. The lab test cost was $15. After that experience, I would not see their patients in my San Clemente office. They had to drive to Laguna Hills, about 15 miles.

    You can blame the professionals but they are doing the best they can in a hostile environment, except for the crooks of course, and Medicaid is full of them. Most physicians do not accept Medicaid in California, just as most good orthopedic surgeons don’t accept workers comp. I’m talking about private practice, of course, and not institutions with salaried physicians. Kaiser does workers comp as another line of business and can generally be trusted. There are many groups in workers comp where one physician may have 20 offices and only visit each one once a month. The care is all by PAs and NPs. The same applies to Medicaid.

    There is an ugly underbelly that is mostly in government programs. It will be interesting to see places like MD Anderson adjust to government care. If we are lucky, we won’t ever know. Complex care is expensive and will be the first to go.

  7. Doctor, why is there 1 price for insurance companies, 1 price for medicare and 1 absurdly high price for the patient who has no insurance? Why can’t there be 1 true price that all three (insurance/medicare/patients) pay?

    In the 1950s doctors had 1 true price and that was what they were paid. But if you were poor you got a discount. Hospitals did the same.

    What happened?

  8. Dr Kennedy your explanation in #7 is a real eye opener. I never knew. What is a profile fee? Does Medicare really demand 90% off profile?

    I assume in Jimbino’s case that the $4500 colonoscopy is the price for people without insurance, that $1930.00 is the “profule” fee and $193 is the 90% off medicare price. What keeps MDAnderson from charging $193 to people without insurance? Is it against the law?

  9. When you first go into practice and register as a Medicare provider (A lot of this may be out of date as I have been retired for 15 years but I keep up), they establish a profile of your fees. What happened in the 70s and 80s was a steady fee inflation but it did not apply to the profile. If I charged $600 for an appendectomy in 1972, that was my profile subject to small increases for inflation. A new surgeon comes out of training in 1976 and charges $900 for an appendectomy. That becomes his or her profile. Being slow, I figured this out after I had assisted a new surgeon in town with her first case. New surgeons need an observer before they are allowed to do surgery on their own. My office billed for the assistant fee, which used to be 20% of the surgeon fee. My office manager informed me that my assistant fee, for her, was almost as much as my surgeon fee. She was smart and started out high. This, of course, put the pedal to the metal in fee inflation.

    Anyway, the DRG system came in in 1986 and hospitals went to flat fee payment for Medicare. They continued to produce “retail” bills for private insurance but private insurance soon went to negotiated payment using the Medicare model and the DRG schedule. The retail bills survived but meant little for most of their business. The insurance companies were in competition with each other and the bigger “discount” off the retail price they could get, the better they were in competition with small competitors. One place the retail bill survived is in outpatient surgery. Since the DRG did not apply to outpatient units, hospitals quickly built outpatient surgery facilities. Soon, negotiated prices took over here but with a twist. Many of us have high deductible insurance with a typical 20% co-pay.

    Let’s say we have a bill from the surgery center of $8,000 for some procedure. Our 20% co-pay is $1600. The insurance pays “the rest.” What do you think the rest is ? Probably less than your 20% co-pay. That’s one reason why it is so difficult to find out the retail price. You might be unhappy to learn that your 20% amounted to more in real dollars than the “80%” paid by your insurance.

    This is a complicated business and some of my information is out of date but my wife is an OR charge nurse and I hear all her stories plus docs still gossip about things. The pricing system has become so distorted that the incentives are all screwed up. That’s one reason why so many docs are just dropping quietly out of the system. Most of them are older and have established practices and have probably gotten enough commitment from patients that they know it will work.

    New docs are out of luck.

  10. One comment on the law and cash fees. Medicare, somewhere in the law, says that it must get the best price available in the community. Don’t rely on my information but it is something like that. If I provide a service at a lower price than I charge Medicare, I am in violation of that law. Also, it is a legal requirement to charge the patient the co-pay, which is 20%. They don’t enforce these laws, in my own experience, except in cataract surgery where they cracked down on eye surgeons who advertised that they did not collect the co-pay. I’m sure they would go after MD Anderson if they found out about it. I used to charge smaller fees for uninsured people but didn’t talk about it.

  11. You know that, separately, the recommendation has been made to back off on Pap smears. Seems that young women just don’t die of cervical cancer that often. Which is interesting, because every effort has been made to mandate HPV vaccination for both male and female teenagers, to combat the terrible scourge of cervical cancer.

    You are damn right that I experience “distrust”.

    Tatyana’s right, you have to be your own doctor. I been knowing that.

  12. This is a great discussion!

    Michael Kennedy – I learn so much from your comments! If more physicians are taking themselves ‘off the grid’, I wonder how long it will take for requisite authorities to notice, and then, tax said behavior(even more)?

    Tatyana – that was the point I was getting at; we are adding another layer of distrust to the relationship. Already, it’s not healthy. As this thread shows, lots of people are unhappy. I’m not defending the current system so much as pointing out the problems with the supposed ‘fix’.

    Mrs Davis – I miss living in the ‘stix’ sometimes, too, but that’s mainly related to noise and traffic….

    Charles Silver – I think distrust exists in all systems, because as a physician, you implicitly ask for trust. “Trust me to treat you.” The amount of distrust, and the object, changes depending on the system.

    Jimbino – I agree with you, actually. I feel ashamed every time I pass a Health Care Clinic in a CVS, or other drugstore, and think this all should have started earlier, and be championed by the standard medical organizations.

    Sol Volason – what happened is that it all got so complicated, by historical accident and willfull regulation. Well, that’s my opinion.

    Anonymous – Ha!

    Laura(southernxyl) – it sounds cliched, but you have to be your own best advocate. I instruct patients to keep careful copies of their own medical reports (I work in the lab) and not to rely on anyone else for this.

    Thanks again for the comments!

  13. One last comment about outlawing or taxing this trend. Private practice in Canada has been relegated to a tiny minority since it was illegal to do private care and to participate in the national plan. That is now changing, especially since the chief justice ruled that “a health plan is not the equivalent of health care.” This has been some time ago. It is growing but the LA Times is often behind the times in their stories.

    Hoping to capitalize on patients who might otherwise go to the U.S. for speedier care, a network of technically illegal private clinics and surgical centers has sprung up in British Columbia, echoing a trend in Quebec. In October, the courts will be asked to decide whether the budding system should be sanctioned.

    The ruling supported the clinics. I also know of many Canadians who have US private insurance. Spokane has four big medical centers. They aren’t all for the northern Idaho population. Just like Mall of America is not just for local residents.

  14. Thank you Dr. Kennedy. I suppose the special low prices you gave to uninsured people is the source of the $600 billion in Medicare fraud that Obama promises to eliminate. I have heard that compassion and charity were made illegal by Medicare. Now I know it is true.

    It seems to me that the best way to make medical care affordable is to eliminate Medicare. People who do not have insurance have an enormous freeloader problem which is Medicare and its 90% discounts.

    I have Medicare and I know that the premiums I pay per month when combined with the premiums I paid since 1965 when I was 23 are enough to pay my medical bills (including my stroke and open heart surgery) even if I paid twice what medicare pays or even if I paid the same as BCBS. I am sure the same is true of everone who is currently forced to use Medicare.

  15. The thing folks probably don’t understand is, in our computer age nationalized healthcare is not about paying for medical care, it is about regulating healthcare. National healthcare (single payer or forced coverage from ‘private’ insurers) is about government tracking and bureaucratizing every interaction you have with your doctor, and regulating your decisions about your health.

    Already doctors are coerced into using electronic medical records to track “outcomes” and “quality,” to prove to the government they’re behaving the way the government commands. The logic is inescapable. Medicare or Medicaid or some agency is paying medical bills. To be sure they’re getting their money’s worth, agencies demand doctors measure the “quality” of care. What is quality? “Quality” is matching some easily measured statistic with a target. A target some smart guy in DC came up with. A federal employee has decided what your cholesterol should be, and he’s given your doctor a target, an overall average cholesterol for your doctor’s patients.

    So you and your doctor are free to discuss the costs and benefits of your cholesterol control, and decide the treatment that’s right for you. Only, see, if your doctor’s patients, on average, fail to meet the government target, your doctor is punished financially. So how free are you, really?


    President Obama say’s he’s going to mandate all medical records be electronic. The doctor in the Denver ER can supposedly access your records back in LA. Who could argue? What the headline misses is, the EMR isn’t a .pdf scan or a text file. It is a database. Let that sink in. A database. Every symptom you have, every lump on your body, every diagnosis you have ever had, every drug you have ever been prescribed and every drug you have ever admitted taking, every sexual secret you whisper to your doctor is going into a database. In a computer. With a wire. Connected to Washington DC. But they’ll never look. Promise. OK they’re already looking. But they won’t look at your name. Promise.

    Two things about this.

    #1. If the government is paying for something, the government will regulate it . Anything your doctor knows about you can be regulated. Your smoking. Your weight. Your trans fats. Your alcohol. Your seat belt use. Your exercise. Your bike helmet use. Your gun ownership (a standard yearly physical question nowadays). Your sexual activity. The National Health Agency will set targets. The healthcare company your doctor works for will meet those targets or its payments will be cut. Your doctor is about to become the government’s agent in enforcing encouraging lifestyle regulations suggestions.

    Consider the Keith Emerich story http://www.getmadd.com/DontDrinkatHome.htm I’ve read (but can’t find the blog again) that the medical board approved the doctor’s action. Nationalized healthcare will leave us with Emerich’s choice: do we admit our habits and risk being reported to the state and punished, or do we keep our habits secret and risk our doctor missing and not treating important diseases.

    #2 The non-computer costs of electronic medical records are staggering.

    a) With an EMR the doctor’s opportunity costs are high. Detailed data entry must, by regulation, be done by the doctor. Particularly primary care doctors must now spend much of the day as data entry clerks. The shortcuts and workarounds for this make the “facts” in the medical record unreliable. They make medical care worse.

    b) The business killer is regulation compliance costs . Now that the government can measure everything, they can regulate everything. For example, one regulation says doctors must have a language translator available for every patient. California’s state guidelines for language translation services are 112 pages long. Another regulation: if you’re overheard saying a patient’s name in the elevator, you can be fined and go to jail. Translation. Elevator speech. They plan to micro-manage everything.

    Practicing medicine this way cannot be done. It is literally not possible. It is simply not possible for small medical offices, particularly primary care offices that generate lots of paperwork, to comply with industrial level regulation. The kind of small office primary care doctor you and I grew up with is being regulated out of business. Which is probably why in the US now, today, half the doctors in primary care training are foreign medical graduates.

  16. Perhaps Charles Silver would like to explain why if congress is so enamoured with single payer are they keeping their “private insurances for life” plans and not mandating single payer for themselves and the rest of the federal government workforce.

  17. I don’t understand the specific objective of health insurance reform. Does it apply to citizens, or anyone that can cross the border? Does it reduce total costs? Does it increase average health care results, or improve the least health care delivered to a predefined acceptable minimum? Is the goal to improve the average health care related quality of life for all citizens? Or is in fact the goal (or goals) to increase the dependency of even more of the economy on the favorable whims of the responsible partisan government minister, thereby steering even more money to the shlushy campaign coffers used to pay party loyalists and revolving door lobbyists? And make the subjective decisioneering of the medical care availability panels malleable to the force of the dollar?

    Like Woodward & Bernstein, the Occam’s Razor principle applied to determining political motive says “follow the money”.

  18. Jimbino – I understand your confusion and your reaction with the pricing structure of medical procedures. It is a complicated formula driven by a number of factors. First, almost no one pays the list price of a medical procedure. The advertised rates are always discounted. The reason is that when dealing with insurance companies, the insurance company will demand a discount of the procedure for their enrollees. In my field, radiology, those fees are almost always figured as a percent of the Medicare payment. For instance, for interpreting an MRI, we may charge 150% of Medicare. I assume the pricing at M.D. Anderson do the same for colonoscopies. The “list price” is basically incentive for insurance companies to negotiate with the physicians. In other words, if the insurance company wants to pay too little, the medical group may threaten to departicipate and require the company’s enrollees to pay the much higher fare. This is very bad PR for the insurance companies, so it gives them incentive to deal with the provider.

    The reason that there isn’t one fee for Medicare, insurance companies and private pay is that most practices lose money on Medicare. Just think of it, Medicare pays $193 for a colonoscopy. A colonoscopy, from start to finish takes about an hour. That is an hour that a room is being tied up that can’t be used for something else. It has to pay a highly trained physician, a nurse who is trained in administering conscious sedation, the monitoring equipment, the colonoscope, the sterilization equipment, the ancillary personnel who check you in, the billing personnel, the recovery personnel, buying and laundering patient gowns, the drugs used for sedation, the overhead for the office, etc. I think you could probably understand why $193 doesn’t begin to cover the actual cost of the procedure.

    This is why so many practices have stopped accepting Medicare. The fact of the matter is that private pay patients and insured patients subsidize Medicare patients. The Medicare rate is fixed by the government – to charge more than the proscribed government rate to a Medicare patient is Medicare fraud. Incidentally, Dr. Kennedy is absolutely correct, for a Medicare provider to charge less than the Medicare rate (e.g. – free services to the poor) is also Medicare fraud. My father was a general practitioner for years. He used to provide free care to clergy and their families and he would donate his services at a homeless shelter. When, during the Clinton administration, the Medicare rules were changed to prohibit this, he’d have to tell his patients that he was required to send them a bill, but he didn’t expect them to pay it. Of course, in doing so, he was committing Medicare fraud.

    In fact, if I read a CT scan with contrast, but forget to mention that contrast was utilized and my billing office underbills it as a CT scan without contrast, I am committing Medicare fraud. (There are no mistakes. Every deviance is considered fraud.)

    Don’t even get me started on the intrusion of the government into the practice of medicine and all the pitfalls of the proposed electronic medical records.

  19. I was a family doc for 20+ years, and have worked in a workers’ comp clinic for 12 years. Our state (Colorado) has evidence-based “treatment guidelines” that specify what tests or treatment are appropriate for a given diagnosis and when they would be appropriate. Overall it’s a very fair system–fair to the injured worker, the employer and the workers’ comp insurer. Yes, there are outliers (people whose condition falls outside the expected course), and the guidelines have mechanisms to help those folks as well.

    If an insurer (especially the self-insured companies) want to speed things up (such as ordering an MRI sooner rather than seeing how a patient responds to a rehabilitation-based approach), the system allows for this. Well-designed treatment guidelines do control cost and usually reduce inappropriate treatment, so the system isn’t all bad.

    The difference is that the Colorado workers’ comp system uses private insurers, rather than paying for treatment out of state coffers, so the Colorado guidelines place treatment decisions at arm’s-length from payment obligations. The feds, on the other hand, make both the guidelines and the payments, through Medicare (now) and the so-called public option (perhaps in the future)–a typical fox/henhouse scenario.

  20. A comment on the subject of free care, I know that in my area most primary care docs who see Medicaid (MediCal in California) do not submit a bill. They just write it off. We gave up submitting bills for anything but surgery where there was enough potential payment to make it worthwhile. Then we would constantly get notices that the bill had not been submitted within the time limit. At that point, I tried to send MediCal bills by registered mail with a delivery receipt but I was informed that the state did not accept registered mail.

    I spent years on the board of the Medicare peer review organization, called CMRI, and one time we were trying to figure a way to diversify the customer base for the company. If you have one customer, you have little leverage. Anyway, we sent a letter to the state DHS which administers the MediCal program asking if they had any interest in contracting out any services, like quality review. They did not have any interest and it went no farther but I did learn that the state DHS had over 5,000 employees. That was more than HCFA had to administer Medicare. That was 15 years ago. Medicare at the time had about 20 times the enrollees.

  21. Here’s a worthwhile blog which often writes about healthcare……specifically, the application of “Lean” management techniques to the field”


    The blogger, Mark Graban, gained extensive experience in manufacturing before shifting his writing & consulting focus to healthcare.

  22. That’s an interesting web site. I cannot imagine a hospital today tolerating that sort of behavior from doctors. The only place I have seen that sort of behavior was when I was a corpsman in the Air Force in an Air Force hospital. My wife is the OR charge nurse in the hospital that I worked in for 30 years. She has been there over 25 years. She knows all the surgeons and anesthesiologists from years ago and can talk to a couple of difficult people (classically neurosurgeons) but what she sees is the constant threat of harassment suits against surgeons by disgruntled employees. She has actually been subtly threatened with retaliation if she does not endorse a complaint against a surgeon for an incident that she witnessed.

    Nurses are a lot more powerful than they were 30 years ago and they were the noncoms of medicine even then. You alienated them at your peril even then. My niece is an OR nurse in a big Chicago hospital. She decided not to apply to medical school because she did not want the debt and the income is not that much less. She has degrees from U of I and Loyola and the nursing school was very happy to waive her tuition. She would have been accepted to most medical schools. She is happy with her decision. She and her boyfriend also have a successful rock band.

    I have attended meetings on lean methods. One such organization is Lean Healthcare West which will go into a hospital and conduct training sessions. The biggest roadblock is the hospital culture which is very resistant to outside advice.

  23. The doctor-patient relationship is a critical part of understanding the patient’s medical situation, making a diagnosis, and applying effective treatment. Patients value this relationship, particularly as it develops over time during an ongoing relationship. I learned more from this book called, “Time to Care” by Norman Makous, M.D. Inside it is filled with dozens of case anecdotes that illustrate this.
    More should read this book.

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