Before the outbreak of Covid-19, we knew our healthcare system had serious gaps. We knew that the business of medicine had come with significant impact to the treatment of patients. Then the pandemic broke out and elevated these issues to the forefront of the national dialogue.  

As a country, we are at a crossroads. Yes, we are in the midst of serious clashes over significant cross spectrum of issues, including health care. I’m certainly not an expert on everything, but I have lived through significant changes in the healthcare system, and I believe it’s important we all understand how we got here…and where “here” is. To put it all in perspective, I’d like to give you a peek into what healthcare used to look like. Perhaps you remember.

Before the big business of medicine took hold

My grandfather was a family practitioner. He did everything from setting broken bones to delivering babies. He saw the patients, and my grandmother sat at the kitchen table with the accounting book spread across it, with all the bills piled up. She logged in the names and accounts receivable of all the patients my grandfather saw that day. It was a true family business. The office was connected to the house, so it was my playground, and I easily flowed between the smell of chicken vegetable soup in the kitchen to antiseptic in the office, depending on which side of the house I was in.

I loved it.

I loved the patients who were coming in and out, and the grateful look on their faces when my grandfather helped them. I loved knowing he was caring for so many, bringing life into the world, and sometimes helping the elderly simply grow old with dignity and vitality. He cared. He was smart. He was his own boss, with his own rules, with ethics and morals and a point of purpose that drove his days. My grandmother was the same, with a razor-sharp brain for numbers and business, having run her immigrant father’s store when she was a young girl, doing the books by the age of 13. There was a purpose to both their lives, and it was a simple one: Taking care of people and their families.

Growing up this way is what made me decide to become a doctor.

When I was in my training, I remember the day I found out that the hospital I was training in was joining another hospital, and that, in fact, there were going to be three hospitals coming together to create a “system,” to be run under one umbrella. Ignorantly, I thought, “How cool!” I thought it would be awesome to collaborate with other doctors. I even started a virtual women’s program, working with other women cardiologists throughout the system so we could all come together in support, share our resources, and help people together.

I do remember that some of the more senior doctors were anxious or angry, but I didn’t know why. Ignorance is bliss, I suppose, but it was this ignorance that has, in part, led to the predicament we are in now.

Recently, I read a book by Dr. Elisabeth Rosenthal explaining what I was about to live through. It’s called An American Sickness: How Healthcare Became Big Business and How You Can Take It Back. This book eloquently explains how and why there was a clear “then” and “now” when it comes to healthcare. As I read it, the memories came flooding back, and with Dr. Rosenthal’s insight, what was happening to me—and all doctors—has become even more apparent.

Living through a seismic shift in health care

You see, unbeknownst to the doctors, in the late 1980s the business of medicine was well underway, and by the time I graduated from training in the early 2000s, the hospital system had become a multi-layered business driven by the bottom line.

As Dr. Rosenthal states in her book, “The cost of hospital services has grown faster than costs in other parts of our healthcare system.”

She writes that about 80% of patients under the age of 65 years old were covered by good insurance between 1968 and 1980, so hospitals pushed the envelope, billed the insurance companies, and the insurance companies would reimburse at these high rates.

Essentially, the business of medicine became about hospitals gaming the system, and that changed everything. They began to morph from caretaking facilities to money makers that were then forced to hire administrators to figure out the bottom line. Professional coders who understood the insurance lingo were brought in to figure out how to bill to get even more financial reimbursement, and doctors were trained how to write their notes to code for higher reimbursement rates, too. They were instructed on what procedures to perform more often and in what order, to make sure that hospitals received the maximum revenue.

But many of us didn’t realize this was happening. Even into the ’90s, in many academic institutions, the essence of medicine (caring for patients) was not yet lost to the business of medicine. The clinic I worked in was staffed with doctors in training and there was strict oversight by our academic doctors, training us to be the best we could be.

This was the era of the HMO, and costs were relatively contained. In fact, this was the only decade since the 1940s when US health spending did not increase faster than the cost of living. Unfortunately, however, many of the HMOs were poorly managed and besides Kaiser Permanente in California, most of them died out (thanks for explaining this one, Dr. Rosenthal!). Being only in training, I could never have known that this was the calm before the storm. Things seemed to make sense then. At least, at that time, doctors still valued the big picture of healthcare as a way to help people.

But as I was getting ready to graduate, I remember sensing a shift. I felt it the day my medical license became a valuable commodity to the system. Suddenly, I went from being a student to an employee. Billers began to teach me how to maximize the profit potential of my medical records. They explained coding to me, to ensure that insurance companies reimbursed at their highest level. Electronic medical records made this easier by showing us which boxes to check to get more money.

Administrators made it clear that doctors were dispensable employees who worked for a system to create revenue. Our personal value to the institution was less important than the bottom line of the business. The once-revered position of the Chief Medical Officer of the hospital morphed from being awarded to the most skilled, experienced physician, to a position given to the doctor who was best able to make sure the hospital doctors were financially rewarding to the system.

Today, most every hospital is driven by administrators and consultants, and the terms “strategic alliance,” “the bottom line,” and “reimbursement” have become standard hospital speak, all embedded within the business of medicine.

Doctors’ value is now determined by their financial value—now they call it their RVU, or “relative value units.” This is a measure of productivity, and a means to determine medical billing and how much financial productivity a doctor is creating for the hospital.

Around the year 2000 (I graduated in 2002), hospitals decided they would no longer pay physicians a fixed salary and they would determine their pay by these RVUs. This really changed the game because if doctors became incentivized to see more patients and do more procedures that would then get reimbursed at a higher rate. The actual care of patients wasn’t (and really, could no longer be) the priority of hospitals or their doctors because everything was centered around and driven by financial gain. What really happened is that doctors lost their power, becoming mere cogs in the wheel of the hospital system.

What could we do? Doctors are caretakers, academics, and interested in patients and health. Very few were willing or able to fight back or knew the business of medicine within this new healthcare system enough to even know where to begin.

It’s been almost 20 years that I’ve been in the system, as a trainee and then as a physician. I “ran” programs and in my naivete believed I could make a difference and have an impact. It wasn’t until an administrator from my recent position made it clear to me that my value was based solely on my financial benefit to the system that I paused to learn more. I needed to understand why having an impact on women’s heart health was not significant. I did research, and I expanded my own education beyond what was told to me in the system by the system. 

A return to the care of patients

At the beginning of this new decade, I left the hospital, opened my own office, and researched reimbursements and how I wanted to take care of my patients.

My practice differentiates itself in these (and other) simple ways:

·   I decided 15 minutes was too short for a thorough appointment with a patient, and an hour seemed right.

·   I decided I wanted my staff to feel valued and appreciated.

·   I wanted my patients to know how much I honor their trust and how much I value our relationship.

·   I wanted to go back to the days when my grandma just wrote down the accounts receivable for the day for the true heart-driven work my grandfather put in on behalf of his patients.

I can’t go back in time, of course, but maybe I can set an example for a future of health care that values the patient again. For the first time, I feel like I am on the right track to making an impact and changing healthcare. I am no longer a cog in the wheel. I am taking care of patients the way we all deserve to be cared for: with passion, with purpose, with research, and most importantly, with my heart.