Is BIG Better?

I’m not convinced that BIG MEDICINE is better than small medicine.  I grew up in a family that owned a paint and wallpaper store.  Customer service was a large part of what they sold.  Over the years, we have seen “mom and pop” operations bought out and replaced by chains who offered somewhat lower prices.  The remaining “mom and pops” could not compete and went out of business.  The chain prices rose, but the service component was lost forever.

Big Medicine is heading that way.  Physicians who were solo practitioners have had so many external requirements placed on them by government, insurers, HMOs and other entities, that they would have no time to see patients unless they formed groups and hired management to deal with the bureaucracies, Many or most computerized the business side of the office, but now the government has mandated that medical records be computerized.  This is not to improve the care of patients, but rather provide data to those external groups who pay for health care and want to find ways to pay less.

Other creative ways to control costs are included in the Health Care Reform bill.  Accountable Care Organizations (ACOs) will be created.  These are large entities made up of many thousands of patients who will get their entire care from the ACO.  The payers, especially Medicare to start, will pay so many dollars per year for your care.  The ACO will have to decide how much each member gets paid from that money – a monumental challenge.  Is the cardiac surgeon worth more than the chief financial officer?  Is the emergency room nurse worth more than the nurse practitioner on the cardiac floor?  Is a gastroenterologist who does hundreds of endoscopies worth more than a hematologist who does few procedures?  In fact, the gastroenterologist may argue that his/her services generate a lot of charges, so is therefore worth more.  The hospital may counter that the income is now fixed in the ACO and all you are doing is spending the profits!

Part of the theory of ACOs is good.  Spend more time at the primary care level talking to patients and sorting out the issues rather than sending them quickly for a lot of tests and procedures. That presupposes that the primary care physician is well suited to that task.  Certainly the senior ones who trained in the 60’s and 70’s are, but I’m not so confident that the younger primary care physicians have that breadth of clinical knowledge.  The medical profession has been pushing for standards of care for the past 20 years.  Guidelines, generated from “Evidence Based” clinical research studies have medicine much more cookbook in nature. They do not translate to direct patient care in a clinical setting very easily. Physicians are currently, at least in part, paid on the basis of measurable performance standards like asthma Rx, or ordering certain blood tests to follow a diabetic patient.  These are computer measurements, easily extracted from a computerized medical record.  Hence, we see the logic of the government’s approach.  These measures do not translate to the quality of care the physician is really giving the patient.

We’ll talk more about what quality of care really means in an upcoming blog.

Gerald L. Evans, M.D.