Sometimes things just come together and paint an undeniable picture that you had never seen before.  Yesterday, after posting my blog about physician burnout and suicide, I read an article on KevinMd that mentions the switch from pay per service to a quality-based payment system.  When I finished reviewing Kevin’s daily articles, I came across an expose on Bit coins and how they function.  These seemingly unrelated articles started me thinking and led to an epiphany.

What became crystal clear was that my generation is responsible for the demise of the medical profession.  I helped kill the thing I loved, my calling.  Let me explain.

“Value is in the eyes of the beholder.”  When you are clothes shopping and find a shirt you love, you buy it.  Yep, you go to the cashier, pull out cash or a credit card and, having paid take your new shirt home.  Can you imagine going to the cashier and telling her/him that you left your wallet at home and you would pay for the shirt later or that your insurance company would pay a discounted amount if you send the bill to them? Of course not.  The store functions on a fee for service basis.  The store sets the price and you decide if the shirt is worth it.

Can you imagine pulling up to the gas pump and filling your car’s tank to the brim, then driving off without paying?  Or eating a meal at your favorite restaurant and skipping out on the bill with your leftovers and a bottle of wine?  Of course not! You would be arrested!

“But judge, I would have eventually paid for those services.”

“They should have sent the bill to my insurance first.”

“It’s only $10 dollars.”

“I never got a bill.”

My staff has heard it all.  If the clothes store, gas station or restaurant were run the way the medical system in this country is run, they would all fail.  Not only would the businesses fail, but the people who owned and managed them would suffer from burnout and their suicide rate would rise.

So, how did my generation kill the medical profession I love?  It’s all about setting a “value” on an item.  When I started in medicine, physicians and patients set a high value on their relationship and practice.  Some placed physicians on a pedestal.  It was a fee-for-service relationship much like in the examples of the retail world above.  I set the fee, the patient decided if seeing me was worth it (my value) and paid on the way out the door.  If patients had insurance, they would submit a claim and be reimbursed according to the policy limits.  Billing expenses were minimal, and my wife handled the paperwork and billing herself.

At some, my cronies and I fell into a trap.  We allowed the insurance company to insinuate itself between the patient and the physician.  We no longer set our value, the insurer and government did. Over the years, we have lost much of our value, not because the patients no longer valued us, but because the insurer/government/middleman took over and devalued us.  The more the insurer devalued and controlled us, the more profit they made; or, in the case of the government, the less they spent.  The more the insurers and Medicare took over, the more office expenses increased.  At the end, I had two nurses and four full time individuals in the billing department.  My income went down and my patients’ cost went up as did the insurers’ profit and control.

Had we stood our ground years ago, we would not be in the sorry state we are in now.  We find ourselves at another critical intersection.  If, as a profession, we don’t take a stand against a “value” based system, we will finish the job started years ago: the complete destruction and further devaluation of the medical profession.

Remember that if you do not set your own “value,” the insurers and Medicare will, and I guarantee you that what you and I deem valuable will not be what they deem valuable.  A “valued” physician will most likely be a physician who checks every box on the electronic medical record, provides the least expensive care while following the insurer or Medicare’s protocols and avoids unwarranted treatment courses that involve thinking, tests and referrals. 

In other words, a “valued” physician will hate his/her job, be burned out and at increased risk of suicide.  What a pity.

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