Dear Oregon Doctors,

     I recently heard that this HMO Watchdog Site was to begin a new feature in which physicians or others connected with the medical field could write in anonymously. The freedom that anonymity offered sounded very attractive.  Too good for me to refuse.

     I will identify myself, a little anyway.  I'll give you two demographics to chew on.  First, I was a delegate at the recent November 7-8 Oregon Medical Association (OMA)  conference.  Second, I have never in any manner been medically political in the past.

     My prior political position with respect to the practice of medicine was something akin to: "Don't worry, everything will work out for the best." Denial had always served me well and there had never been sufficient reason to adopt any other form of psychological defense.

     Until recently, that is.  Try as I might, denial just wasn't working any more.  I could no longer ignore the way I felt.  I hated what had become of the practice of medicine, as I had known it: I felt like my patients and I were getting cheated, the insurance companies and the hospitals were making off like bandits, and there was no one coming to the rescue.  I knew also that if I didn't stand up for my beliefs, soon, things were just going to
get worse.  I had to go public with my dissatisfaction.

     I was still not fully in the real world of medical politics, however, for I naively fantasized that as a delegate to the OMA I could simply explain my grievances--they were clearly true and good--and someone with a kind heart and massive political punch would step forward, put a comforting arm around my shoulders and tell me not to worry, that everything was going to be OK.  Most likely, this person would be wearing a cape.

     To my surprise and delight, there was no shortage of OMA delegates who felt the same way I did about our professional situation.  In fact, the general tenor of the conference was one of anger and frustration. For two days there was a steady stream of speakers to the floor microphones, venting their dissatisfaction, and at times, rage, with the current medical milieu.  


    Much of the second morning was devoted to a presentation by Mr. Joe Henery of how Oregon Health Plan funds have been divided between doctors and hospitals since the plan's inception.  He had found that over the last five years the share received by the hospitals had increased by 52% and the share received by the physicians had decreased by almost 8%. Understandably, this situation was felt to be very unfair since most doctors lose money when caring for OHP patients.

     At the conclusion of the conference I felt that we OMA delegates had accomplished a lot.  We had spoken out both honestly and fairly.  Measures were passed which if enacted would improve either our situation or our patient's situations.  Surely, anyone who had been there would realize that what we said was true and the reparations we wanted were just.  How could anyone feel otherwise?

     That question was answered abruptly the following Monday morning in the Oregonian, on page one of the Metro section, in an article written by Patrick O'Neill.  The title of the article was, "Doctors, hospitals bicker about state health plan payments."

     Bicker?  The word "bicker" means "to have a petty quarrel.  A squabble." Is that what we had been engaged in?  Here we had imagined ourselves as little Patrick Henrys inflamed with the injustice of a medical situation gone mad, but we were just involved in a "petty quarrel?"  Obviously, Mr. O'Neill doesn't own a cape.

     Now I was really in trouble.  I had already had to jettison denial as a psychological defense and it was additionally clear that I was also going to have to abandon my rescue fantasies.  No one was going to save us. Could we save ourselves?  Sorry, I don't know.

     What I do know is that besides being given this opportunity to write anonymously, the OMA conference and its journalistic consequence has freed us to loosen our tongues.  For no matter what doctors say, no matter how high-minded or true, no one is going to take our complaints seriously.  Our words are just trees falling unheard in the forest and we can therefore make all the noise we want.  We're just bickering.

     Using this newfound freedom, I want to bicker about a topic that is taboo among medical practitioners.  Something that doctor's really can't talk about.  That topic is…well, its MONEY. 


     Now I know that there are many aspects of Oregon medicine circa 1998 that need talking about and changing.  The biggest one is the impact of managed care on patient care itself.  Any system of health care owes it's patents the very best in care.  The reason that I am not addressing that issue is that patient care can be addressed and is.  MONEY can't.

     There are a couple of big reasons why it is taboo for doctors to speak about MONEY.  The first is historical.  The practice of medicine in the Western World is descended from the priesthood.  Ancient healing was a religious act in which the Gods were asked to intervene on behalf of the sick.   In Modern Ancient Times, twenty years ago, that mystical aura still surrounded medicine.  Now, of course, we're all just Providers working on the medical assembly line, punching out The Product for Mr. and Ms. Bossman.  As a result of this minor change in status we've probably lost a little of our mystical quality, but in the dawn of medicine doctors were quasi-religious figures and were not supposed to be in it for the MONEY. Well, maybe just a little MONEY for some nice robes and a big hat, but nothing too ostentatious.  Back then a too obvious attraction to money was a dead giveaway that a doctor-priest was more interested in worldly possessions than he was in helping the sick.  Doctors with an obvious monetary bent were considered second-rate healers and kicked out of the profession.  Some historians believe that these individuals eventually evolved into modern-day hospital and health insurance CEOs, but no one knows for sure.

     This tradition of doctor as priest lives on today, to our undoing.  We cannot complain too loudly about our how we are GETTING CHEATED OUT OF OUR MONEY because it would be unprofessional.

     The second reason that doctors can't discuss MONEY openly is that it's against the law.  Now I've never really understood this notion.  Others have explained it to me several times.  I hear the words and nod my head in assent when the words enter my ears, but I've never really comprehended their meaning.  Doctors talking openly to each other about their fees is apparently considered price fixing and is therefore punishable by death. To get around this doctors are supposed to pay some MONEY to an IPA and let them talk to the insurance companies and hospitals about their MONEY. Although this is theoretically a good idea, I have never been impressed that paying an IPA to negotiate your contract is any better than signing the damn thing yourself and sending it back, but maybe I'm missing something.


     Doctors have also been forbidden to organize.  More price fixing.  Or is it collusion and racketeering?  Or is it all three?  I'm sorry, but I get confused about which term describes which of the many crimes we might commit.  Maybe you do, too.  Anyway, it is illegal for doctors to bargain collectively.

     The combined effect of both our historical and legal situations is that we are economically helpless and at the mercy of both the federal government and the huge corporations that dispense our pay.

     Now I know that nobody except doctors listen when doctors start talking about how they are not getting paid enough MONEY.  The truth of the matter is that it is human nature to think that anyone who makes more MONEY than you do, regardless of what either of you does for a living, is making too much.  We all think rock stars and professional athletes make too much MONEY.  It is not a topic worth arguing.  We know the tremendous sacrifices we made to become doctors, we know the awful burden of what we do, and we know that the current system underpays us for doing it.

     When I first entered practice in the mid '70s I joined another physician and initially shared his secretary who answered the phone, scheduled the patients and tests, kept the ledger, did the billing, and typed the dictation.  It was soon clear that working for two physicians was a little too much for one secretary, and so we hired another secretary.  For years I functioned perfectly well with a single do-all secretary.  My secretary was so skilled, in fact, that she could even smoke while performing her duties.

     The reason that I mention this is because sometimes I wonder if the bodies that pay us realize how expensive it has become to operate a medical office.  Now, our little office employs 2.2 full time secretaries per physician, we send out the typing and will soon be purchasing a twenty thousand-dollar computer system.  Since 1982 my salary has remained static and I am seeing twice as many patients.

     A few months ago our office received a letter from some branch of the federal government announcing that it would soon be enforcing "Medicare Guidelines" to insure that the government was really getting the medical services that it was paying for.  Our particular set of Guidelines was unreal.  To get paid the usual huge Medicare payment of one-half of what we normally charge for a given service we had to…well I'm not even going to describe all the things that we were supposed to do before we were eligible to receive the pittance that Medicare pays us.  It's too demeaning. Basically, we were supposed to perform everything short of doing the patient's genealogy, astrological charts, and washing their car.  If we really did what the Guidelines told us to do a simple consultation would take an entire morning.



     And who was going to oversee the enforcement of these Guidelines?  The FBI, of course.  Apparently one hundred and fifty FBI agents had been pressed into service to make sure that our billings matched our Guidelines.  And what if our billings didn't match?  Well, that was Medicare fraud.  Also punishable by death.

     And to add insult to injury, even though the Medicare Guidelines were not supposed to go into effect for a few months from the time that first notice arrived, almost immediately our office was notified by our major payor that
they had downgraded several of our prior charges for not conforming to Medicare Guidelines.  In other words, these astute business people had instantaneously tumbled to the financial possibilities of the Medicare Guidelines and were eager to get in on the profits, even before Medicare itself was putting the Guidelines into effect.

     At that point in my professional life I had had it.  Just when I had thought the powers-that-be had run out of financial indignities to put us through someone had come up with one more.  I reasoned that there must be a think tank somewhere devoted to separating doctors from their MONEY.  But praise the Lord, the Cavalry came to our rescue.  The AMA, responding to the outcries of outraged physician across the country, negotiated a suspension of the Guidelines.  At least for now.  Like the slasher in a horror movie, the Guidelines are still alive somewhere, waiting for their sequel.

     Back in the days when HMOs were just a gleam in some administrator's eye, I attended those conferences that presented the sorry state of medical economics in America.  If you are old enough, I'm sure that you remember them too.  Basically these presentations consisted of a graph in which rising medical costs were plotted against gross national product.  After presenting the current financial numbers, the speaker would then sadly extend his pointer beyond the right edge of the screen to indicate that if medical costs were projected into the future, by the year 2010 every penny of our gross national product and then some would go into medical care and no one in America could afford cable TV.  Upon seeing this information, I was filled with remorse.  Yes, of course we had to do something.  Medicine had become a monster.  I would be a willing participant in whatever had to be done to kill it.

     I am beginning to suspect that what we heard then about medical costs was a close relative to what we heard in the early 70's about the imminent depletion of fossil fuel.  But to really believe such a notion about medical costs, I would have to become a complete cynic, wouldn't I?  Well, I'm not ready to take that step.  Yet.



     It's true, however, that during that period medical costs were rising rapidly, but I believe I have an explanation for their increase that I never heard given its proper importance in the conferences.  At least I have an explanation for some of my own practice habits during that period. Remember lawyers?  Remember how we feared that they were going sue us into kingdom come if we made an error or maybe even if we didn't?  During that dark period I can recall ordering every medical test known to man on any patient who displayed even the slightest dissatisfaction with their care fearing that I might miss something and get sued.  Then, when these tests returned normal, still fearing I might be missing something, I would refer the patient on to another specialist, who in turn referred them to still another specialist, who then...

     During that time, I also remember attending conferences in which we were warned to practice "defensive medicine."  Remember how the extent of our liability for medical malpractice claims was explained to us in gory detail?  In brief, the plaintiff attorneys, our wronged patients and their families would swoop into our neighborhoods like Vikings, seize all our possessions, burn our homes, defile our spouses, and cast our children into
slavery.  In response to these lurid descriptions we fearfully lined up to buy more medical malpractice insurance like it was fresh bread in a Russian supermarket.  I'm sure that our reaction was good for both the lawyers who now had access to more insurance money and for the insurance agents who were selling us malpractice insurance.  It just wasn't good for us.

     I have always had the feeling that if we hadn't had to defend ourselves in such a ridiculous manner from the threat of malpractice suits the cost of medical care would have been much more reasonable and the abomination known as managed care would never have happened.  In an effort to be totally honest about managed care, however, I do have to admit that it is not all bad.  It has produced one decided benefit in my life.  I no longer worry as much about lawyers.  I'm sure they are still out there, ready and eager to sue me, but I bet medical malpractice litigation isn't the growth industry it once was.  Since HMOs have made mediocrity the new standard for medical care there is less pressure on us to perform consistently exceptional work.

     In the early days of managed care, I used to feel sorry for hospitals and insurance companies.  They saddened me with their recitations of how much money they, too, were losing from managed care.  We doctors with our profligate ways were costing them so much money.  Over time those feelings have disappeared and have been replaced by anger that we doctors have been the unwitting dupes in an economic situation for which we currently have no means of redress.  WE WANT OUR MONEY! 


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